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HEALTH PROMOTION NEEDS OF STROKE PATIENTS

ACCESSING COMMUNITY HEALTH CENTRES IN THE

METROPOLE REGION OF THE WESTERN CAPE

BY

DEBBIE BIGGS

A thesis submitted in fulfillment of the requirements for the

degree of Masters of Science in the Department of

Physiotherapy, University of the Western Cape.

November 2005

Supervisor: Mrs. Anthea Rhoda

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HEALTH PROMOTION NEEDS OF STROKE PATIENTS

ACCESSING COMMUNITY HEALTH CENTRES IN THE

METROPOLE REGION OF THE WESTERN CAPE

DEBBIE BIGGS

Key Words Health Promotion Health promotion needs Stroke Disability Rehabilitation Health promoting behaviours Health risk behaviours Secondary Complications Quality of life Community Health Centres Western Cape

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DECLARATION I hereby declare that “Health promotion needs of stroke patients accessing

community health centres in the Metropole region of the Western Cape” is

my own work, that it has not been submitted, or part of it, for any degree or

examination in any other university, and that all the sources I have used or

quoted have been indicated and acknowledged by means of complete

references.

Signature: ………………………….

Debbie Biggs

November 2005

Witnesses: …………………………

Mrs. Anthea Rhoda

…………………………

Dr. Josè Frantz

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ACKNOWLEDGEMENTS I would like to thank Anthea Rhoda, my supervisor, for her advice, guidance and

continuous support.

I am incredibly grateful to all those who participated in the study, for their

generosity and trust to let me into their lives. I also wish to thank all those who

facilitated me during the process of data collection.

I wish to thank Dr. T Kotze for his guidance on statistical analysis.

I would like to thank all my colleagues for their critique and advice, and to all

those that I have not mentioned, and whose contribution was invaluable to this

study, I am indeed grateful.

Finally, I wish to extend my sincere appreciation to my parents for their words of

encouragement and enduring support in the completion of this study.

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ABSTRACT

Stroke is the third leading cause of death and a major cause of disability in most

societies. Individuals with physical disabilities are at risk of secondary

complications due to the impact of the disability, which may be exacerbated by

poor lifestyle choices. Although disabled persons desire to engage in wellness-

enhancing activities, limited programmes based on their health promotion needs’

assessment have been developed. The aim of the present study is to determine

the health promotion needs of stroke patients accessing selected Community

Health Centres in the Metropole region of the Western Cape. A cross-sectional

survey, utilizing a self-administered questionnaire and in depth interviews with a

purposively selected sample was used to collect the data. The quantitative data

was analysed using Microsoft Excel ®. Means, standard deviations and

percentages were calculated for descriptive purposes and the chi-square test

was used to test for associations between socio-demographic and health-related

variables. Audiotape interviews were transcribed verbatim, the emerging ideas

were reduced to topics, categories and themes and finally interpreted. In order to

qualify for between-method triangulation used in the study, complementary

strengths were identified by comparing textual qualitative data with numerical

quantitative results and vice versa. The quantitative analysis revealed that the

participants were engaging in health risk behaviours such as physical inactivity,

substance usage, non-compliance to medication use and inappropriate diet

modification. Lack of financial resources, facilities and access to information

predisposed them to involvement in risky health behaviours. In-depth interviews

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supported the quantitative findings and revealed that numerous participants’

suffered from depression and frustration as a result of having a stroke. The

necessary ethical considerations were upheld. The outcome of the study could

contribute to the need to develop, encourage and promote wellness-enhancing

behaviours and activities to improve the participants’ health status and ultimate

quality of life.

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TABLE OF CONTENTS

TITLE PAGE i

KEY WORDS ii DECLARATION iii ACKNOWLEDGEMENTS iv ABSTRACT v TABLE OF CONTENTS vii LIST OF FIGURES xiv LIST OF TABLES xvi

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CHAPTER ONE: INTRODUCTION

1.1 INTRODUCTION 1 1.2 BACKGROUND 1 1.3 SIGNIFICANCE OF THE STUDY 8 1.4 RESEARCH QUESTIONS 10 1.5 AIM OF THE STUDY 10 1.6 OBJECTIVES 10 1.7 DEFINITION OF TERMS USED IN THE THESIS 11 1.8 SUMMARY OF THE CHAPTERS 13

CHAPTER TWO: REVIEW OF LITERATURE 2.1 INTRODUCTION 16

2.2 DEFINITION AND CAUSE OF STROKE 16

2.3 EPIDEMIOLOGY OF STROKES 19

2.4 PREVALENCE OF DISABILITY 22

2.4.1 Disability Post-stroke 24

2.5 CONCEPT OF HEALTH PROMOTION AND DISABILITY 25

2.6 FACTORS THAT INFLUENCE HEALTH BEHAVIOURS 30

2.7 CONCEPTUAL MODEL OF HEALTH PROMOTION FOR

PEOPLE WITH DISABILITIES 38

2.7.1 Contextual factors 41

2.7.2 Antecedent factors 44

2.7.3 Health-promoting behaviours 46

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2.7.4 Quality of life outcomes 50

2.8 INVOLVEMENT IN HEALTH-PROMOTING BEHAVIOURS 51

2.9 HEALTH PROMOTION NEEDS OF THE PHYSICALLY

DISABLED 56

2.10 THE USE OF BETWEEN-METHODS TRIANGULATION 60

CHAPTER THREE: METHODOLOGY

3.1 INTRODUCTION 62

3.2 RESEARCH SETTING 62

3.3 STUDY DESIGN 65

3.4 RESEARCH SUBJECTS 67

3.4.1 Sample for the quantitative data collection 67

3.4.2 Sample for the qualitative data collection 68

3.5 EXCLUSION CRITERIA 69

3.6 METHODS OF DATA COLLECTION 69

3.6.1 Quantitative data collection 69

3.6.1.1 Instrumentation 69

3.6.1.2 Development of the questionnaire 69

3.6.1.3 Peer review 73

3.6.1.4 Pilot study 74

3.6.1.5 Translation, reliability and validity of the

questionnaire 76

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3.6.1.6 Procedure 78

3.6.2 Qualitative data collection 79

3.6.3 Trustworthiness of the qualitative data 80

3.7 DATA ANALYSIS 81

3.7.1 Quantitative analysis 81

3.7.2 Qualitative analysis 82

3.8 ETHICAL CONSIDERATIONS 83

CHAPTER FOUR: RESULTS

4.1 INTRODUCTION 85

4.2 RESPONSE RATE 85

4.3 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF

THE PARTICIPANTS 86

4.3.1 Gender, age 86

4.3.2 Gender versus locality 87

4.3.3 Marital status 88

4.3.4 Employment status, educational level and

access to transport 89

4.3.5 Associated medical conditions/illnesses 91

4.4 INFORMATION RELATING TO STROKE 92

4.5 HEALTH RELATED BEHAVIOURS 96

4.5.1 Participation in physical activity and influencing

factors 96

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4.5.1.1 Physical activity participation in relation to

age 96

4.5.1.2 Physical activity in relation to gender and

educational level 98

4.5.1.3 Physical activity in relation to the length

of time that has passed since the stroke 99

4.5.1.4 Barriers to participation in physical

activity or exercise 101

4.5.2 Use of alcohol, smoking and influencing factors 106

4.5.2.1 Substance usage in relation to age

groups 108

4.5.2.2 Frequency of substance usage and age

groups 109

4.5.2.3 Substance usage in relation to gender

and education 110

4.5.2.4 Substance usage in relation to time

elapsed since having the stroke 112

4.5.2.5 Physically inactive participants and

substance users 113

4.5.3 Factors influencing the change of eating habits/diet 115

4.5.3.1 Barriers to changing eating habits/ diet

in relation to gender 116

4.5.4 Compliance to medication use 117

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4.6 KNOWLEDGE ABOUT STROKE 118

4.7 SUPPORT 120

4.8 PARTICIPANTS’ PERCEIVED HEALTH-RELATED NEEDS 122

4.9 SUMMARY 126

CHAPTER FIVE: DISCUSSION 5.1 INTRODUCTION 127

5.2 GENERAL FINDINGS RELATED TO DEMOGRAPHIC FACTORS 127

5.3 PARTICIPANTS LIFESTYLE BEHAVIOURS AND INFLUENCING

FACTORS 130

5.3.1 Participation in physical activity or exercise 131

5.3.2 Barriers to participation in physical activity 133

5.3.3 Alcohol use, smoking and influencing factors 137 5.3.4 Diet modification post stroke 140

5.3.5 Compliance with use of medication 141 5.4 SUPPORT 144 5.5 PARTICIPANTS’ PERCEIVED HEALTH-RELATED NEEDS 147 5.6 ASPECTS OF HEALTH PROMOTION 151 5.7 RELEVANCE TO PHYSIOTHERAPISTS AND OTHER REHABILITATION PROFESSIONALS 152

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CHAPTER SIX: SUMMARY, CONCLUSION, LIMITATIONS AND RECOMMENDATIONS 6.1 INTRODUCTION 157 6.2 SUMMARY 157 6.3 CONCLUSION 159 6.4 LIMITATIONS OF THE STUDY 160 6.5 RECOMMENDATIONS 161 REFERENCES 166 APPENDICES

Appendix A Request to conduct the study Appendix B Letter of consent from the Department of Health Appendix C English consent form Appendix D English questionnaire Appendix E Afrikaans consent form Appendix F Afrikaans questionnaire Appendix G Xhosa consent form Appendix H Xhosa questionnaire Appendix I Qualitative interview guide

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LIST OF FIGURES FIGURE 2.1 Conceptual model of health promotion and quality of life for people with permanent physical disabling conditions 40 FIGURE 4.1 Gender distribution according to district 87

FIGURE 4.2 Illnesses in relation to gender 91

FIGURE 4.3 Frequency distribution of the three paramedical sciences 95 FIGURE 4.4 Physical activity in relation to age groups 97 FIGURE 4.5 The frequency of participation in physical activity in relation

to the time elapsed since having the stroke 100 FIGURE 4.6 Substance usage in relation to age groups 108

FIGURE 4.7 Substance usage in relation to time elapsed since having the stroke 112 FIGURE 4.8 Number of physically inactive participants’ and substance users and their counterparts 114 FIGURE 4.9 Percentage of participants who changed their diet

according to gender 115 FIGURE 4.10 Barriers to changing eating habits/diet according to gender 116

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FIGURE 4.11 Reasons for not taking medication as prescribed according to gender 117 FIGURE 4.12 The extent to which various health professionals educated the stroke patients 118 FIGURE 4.13 Categories of information received about stroke from health care professionals 120 FIGURE 4.14 Participants’ perceived health-related needs 125

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LIST OF TABLES TABLE 3.1 Distribution of disability in the various Health Districts 64

TABLE 4.1 Age versus gender 86 TABLE 4.2 Marital status versus gender 88

TABLE 4.3 Socio-demographic characteristics of the study sample 89 TABLE 4.4 Tertiary, secondary and primary institutions where participants were admitted 92 TABLE 4.5 Frequency distribution of admittance to rehabilitation 93 centres TABLE 4.6 Frequency of participants’ duration of stay at the

rehabilitation centres 94 TABLE 4.7 Frequency of physical activity participation in relation

to gender and educational level 98 TABLE 4.8 Barriers to participation in physical activity or exercise 101

TABLE 4.9 Substance usage 106 TABLE 4.10 Frequency of substance usage in relation to age groups 109 TABLE 4.11 Substance usage in relation to gender and education 110

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Introduction Health Promotion needs of stroke patients

CHAPTER ONE

INTRODUCTION

1.1 Introduction This chapter begins with a description of the lifestyle patterns and behaviours of

individuals with physical disabilities, mainly those who have had a stroke. In the

background, the vunerability of individuals with stroke to secondary complications

is explained. This susceptibility can either be due to direct impact of the disability

or poor lifestyle choices. The rationale and significance of the study is also

explained. Finally, research questions and the aims of the study are stated. The

chapter ends with the definition of terms used in the study, and a summary of the

chapters.

1.2 Background

Stroke is the world’s third highest cause of death and a major cause of disability

(Bakas, Austin, Okonkwo, Lewis & Chadwick, 2002). The impact of stroke on an

individual is vast and stroke sufferers are often left with a resultant disability.

Physically disabled individuals, including those who have suffered a stroke, are

highly susceptible to secondary health complications which may arise after a

primary disability (Pope & Tarlov, 1991). In a report entitled ‘Preventing

Secondary Conditions Associated with Spina Bifida and Cerebral Palsy’, it was

noted that secondary complications affecting people with disabilities include

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osteoporosis; osteoarthritis; decreased balance, muscle strength, endurance,

fitness, and flexibility; increased spasticity; weight problems; depression; and

other conditions (Marge, 1994). In stroke patients these secondary

complications do not only include contractures, spasticity and pressure sores but

also include psycho-social adjustment to depression, isolation and environmental

issues such as architectural inaccessibility (Frey, Szalda-Petree, Traci &

Seekins, 2001). According to the National Guideline on Stroke and Transient

Ischaemic Attack Management (2001), depression and feelings of isolation

should not be overlooked and should be attended to at outreach rehabilitation

services such as the community health centres, rehabilitation clinics, day

programmes or home visits by members of the stroke team / home based care

team. The occurrence and severity of secondary conditions can further limit a

person’s ability to perform essential life tasks and social roles (Coyle, Santiago,

Shank, Ma & Boyd, 2000).

In addition to being predisposed to secondary complications, stroke patients

often also have predisposing illnesses that have been identified as modifiable

risk factors for stroke. These illnesses include hypertension, diabetes mellitus,

cardiac disease and hyperlipedemia (Pohjasvaara, Erkinjuntti, Vataja & Kaste,

1997). Excessive alcohol use and smoking have also been identified as

modifiable risk factors for stroke (Pohjasvaara et al., 1997). According to the

National Guideline on Stroke and Transient Ischaemic Attack Management

(2001), such risk factors place individuals who have suffered a primary stroke at

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a greater risk for a second stroke. The second stroke is most likely to occur

within 1-2 weeks of the first stroke, especially if the first event was an embolus

arising from the heart or stenosis of the carotid artery. The second stroke may

result in severe disability (National Guideline on Stroke and Transient Ischaemic

Attack Management, 2001). Individuals who have suffered a stroke are extremely

vulnerable, mainly due to poor choices of lifestyle such as poor nutritional

strategies, smoking and alcohol use and physical inactivity (Stuifbergen &

Rogers, 1997). The above factors have a negative influence on the health status

of the individual who has suffered a stroke.

Health is not a static entity but rather a dynamic one that is multifactorial in

nature and shifts back and forth on a continuum from low (poor) to high

(excellent) and high to low during the course of a person’s lifetime. The person

who exercises regularly and has good dietary habits, may be at the high end of

the health continuum at the age of 40 years, but after being diagnosed with

cancer and going through several chemotherapy treatments, there would be a

shift in health to the lower end of the continuum. Once treatment is completed

and the person resumes a healthy lifestyle, there could presumably be a shift

back to the higher end of the continuum (Rimmer, 1999). Variations in health

during the course of a person’s lifetime are no different for people with

disabilities. Someone who has sustained a spinal cord injury but practises good

health habits by eating properly, exercising, receiving regular medical checkups,

preventing pressure sores, and maintaining adequate body weight, could be

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considered to be on the high end of the health continuum. Alternatively, a person

who has suffered a stroke that gets frequent pressure sores, has a poor diet,

does no exercise, and is overweight, would most likely be in poor health and at

the low end of the continuum because these factors will often have detrimental

consequences (Rimmer, 1999).

A person with a disability can improve or worsen his or her health in the same

manner as anyone else. The only difference, however, is that people with

disabilities often start at the lower end of the health continuum due to secondary

complications and predisposing illnesses such as diabetes and hypertension,

that overlap with their primary disability (Marge, 1994). These modifiable risk

factors and secondary complications can be further aggravated by the lifestyle

the person engages in following a stroke. The choice of lifestyle an individual

affected by a disability engages in, often has an impact on the individual’s quality

of life. A habitual lifestyle that involves health-promoting behaviours such as

proper medication usage, being physically active and good hygiene, certainly

enhances an individual’s health status. On the other hand, practising health risk

behaviours which include physical inactivity, poor hygiene and smoking, are

potential dangers, which often result in poor health conditions and ultimately a

poor quality of life (Mutimura, 2001).

Researchers are searching for answers as to what motivates some people to

engage in a healthy lifestyle while other people continue to lead an unhealthy

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lifestyle. Health behaviours are reported as being the core of why people behave

as they do and ultimately attempt to explain the multifaceted phenomena of

human behaviour (Manning, 1997). Engaging in health risk behaviours could

compromise the functional mobility of the disabled individual and potentially lead

to an earlier decline in health and a dependency on other individuals for care

(Nosek, 1997; Stuifbergen, Gordon & Clark, 1998; Stuifbergen & Roberts, 1997).

By shifting the focus in health to health promotion, disabled individuals can be

empowered with knowledge to avoid health risk behaviours.

Health promotion is a broad term which is considered to be the aggregate of all

purposeful activities designed to improve personal and public health through a

combination of strategies, including the implementation of behavioural change

strategies, health education, health protection measures, risk factor detection,

health enhancement and health maintenance (Joint Committee on Health

Education Terminology Report, 1991). In a recent working document, Healthy

People with Disabilities 2010, the definition of health promotion for people with

disabilities consists of four parts. The first being promotion of healthy lifestyles

and a healthy environment, the second part refers to the prevention of health

complications (medical secondary complications) and further disabling

conditions, whilst the third part highlights the preparation of the person with a

disability to understand and monitor his or her own health and health care needs.

The final part consists of the promotion of opportunities for participation in

commonly held life activities (Public Health Service, 1998). The health care

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needs mentioned in part three of the above definition of health promotion, can

according to Aday (1993), be characterized as being extensive. The author

states that:

“ (1) their needs are serious, in many cases, debilitating or life-threatening

ones; (2) they require an extensive set of medical and non-medical

services; (3) the growth in the number of stroke patients and the

seriousness of their needs are placing greater demands on the medical

care, public health, and related service delivery sectors; (4) their complex

and multifaceted needs are, however, not adequately met through existing

financing or service delivery arrangements; and (5) federal, state and local

policy makers are increasingly concerned about how to deal with the

demands they place on the existing systems of care, as well as about how

to aid the growing number of people at risk for serious physical,

psychological, and/or social health problems”.

In order to enhance the life of the physically disabled, health care providers and

policy makers are compelled to respond to the health promotion needs. Thus,

despite the increasing interest by individuals with disabilities and health care

professionals in this area, little is known about the health promotion needs and

behaviours of people with various disabling conditions (Lezzoni, McCarthy, Davis

& Siebens, 2000; Stuifbergen & Roberts, 1997). Although this is the case, it is

clear that health services should be orientated towards the prevention of

secondary complications and the enhancement of the health status of stroke

patients by encouraging a habitual lifestyle that involves health-promoting

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behaviours. A general health behaviour curriculum should be provided as a

service to all those living with physical disabilities in South Africa.

South Africa has adopted the district health system for provision of health care

for the country, with large numbers of disabled patients. Medical staffs at

secondary and tertiary health facilities only attend to the disabled individuals if

they have a referral from a primary source, such as a doctor at a community

health centre. The community health centre is therefore in most cases, the first

medical facility the post-stroke individual would access for care (Rhoda, 2002).

Patients who have suffered a stroke form a large group of individuals with

neurological deficit accessing the community health centres in the Western

Cape. Services offered at these community health centres include primary

health care services, which consist of preventative, promotive, curative and

rehabilitative aspects. The rehabilitative services offered to the individuals with

stroke, include mainly physiotherapy and occupational therapy. Individuals who

have suffered a stroke require a rehabilitation programme to function at the

highest level possible, to maintain optimal health, and to adopt an altered lifestyle

(Habel, 1993). Therefore by incorporating health promotion interventions into

rehabilitation programmes, individuals could be more effectively empowered to

take control over their own lives. Although health promotion has been

recognized as a component that needs to be included in the provision of health

services at these Community Health Centres, the emphasis is still on curative

and rehabilitative aspects and less on the preventative and promotive aspects.

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The needs, including the health promotion needs of stroke patients are not

known. The purpose of the present study is therefore to determine these needs

in order to assist the shift of services from a curative to a promotive one.

Addressing the health promotion needs of the stroke patients could form a vital

part of the rehabilitation of these stroke patients. As noted by Renwick and co-

workers, “Rehabilitation has strong potential as a collaborator in the process of

making health promotion people-centered in that it has collective expertise in

client centeredness at the individual level of analysis and application” (Renwick,

Brown, Rootman & Nagler, 1996). According to Teague, Cipriano & McGhee

(1990) “In restructuring health promotion services for people with disabilities,

rehabilitation professionals are challenged to assume the roles of collaborator,

educator, researcher, and programme provider”.

1.3 Significance of the study With healthcare costs on the rise (Pender, 1987) research aimed at empowering

the disabled and their care-givers, can do much to reduce the health, welfare and

economic burden of disability in South Africa (Bhagwanjee & Stewart, 1999).

The findings of this study could contribute to the knowledge of health-related

behaviours of stroke patients as well as the factors that influence these

behaviours. Through the identification of the health-related behaviours of stroke

patients, the health promotion needs specific to this group can be determined.

Results of this study could be used to make recommendations for the

implementation of intervention programmes that address the health promotion

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needs of stroke patients, as well as decrease the incidence and severity of

secondary complications. Interventions based on these study findings could

contribute to improving the quality of life of these stroke patients.

This study attempts to identify factors that influence the health-related behaviours

of people who have suffered a stroke. Most secondary complications are

exacerbated by a poor choice of lifestyle (Coyle et al., 2000). Therefore, efforts

in health promotion intervention should place an emphasis on participation in

health-promoting behaviours such as participation in physical activity, while

refraining from health-risk behaviours, like tobacco smoking and poor eating

habits.

Currently, the health care personnel labour force, mainly the rehabilitation sector,

is overextended because of a small number of health care personnel and the

possible increase in physical disabilities as a result of stroke. The views of the

participants in the study on issues to promote their wellness-enhancing

behaviours could help to prevent the occurrence of additional secondary

disabilities. This could certainly improve the quality of rehabilitation by

decreasing morbidity rates, which will result in lower health care costs (Mutimura,

2001).

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1.4 Research Questions

The specific research questions addressed in this study are:

1. What are the health-related behaviours of stroke patients accessing

Community Health Centres in the Metropole Region of the Western

Cape?

2. What factors influence the engagement by the stroke patients in

these health-related behaviours?

1.5 Aim of the study

To determine the health promotion needs, through the identification of the health-

related behaviours of stroke patients receiving rehabilitation at the Community

Health Centres in the Metropole Region of the Western Cape.

1.6 Objectives

1. To identify the health-related behaviours of the stroke patients.

2. To identify factors that influence the health-related behaviours of stroke

patients.

3. To determine the health promotion needs of stroke patients.

4. To provide health care professionals with recommendations to incorporate health promotion into the rehabilitation programmes of stroke patients.

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1.7 Definition of terms used in the thesis

1. Health-promoting behaviours include physical activity or exercise, eating

practices, seeking of social support, and stress management (Stuifbergen

& Rogers, 1997).

2. Health Promotion in a public health context is intended to maintain and

enhance existing levels of health through the implementation of effective

programmes, services and policies (Chermak, 1990; Smith, 2000). The

concept of health promotion emphasizes self-care and encourages an

active independent attitude towards health care rather than expert care

(Stuifbergen & Rogers, 1997).

3. Health promotion needs are needs from the perspective of the clients.

They are aimed at increasing and maintaining the clients participation in

activities designed to enhance his/her quality of life and control of his/her

life status. They include physical activity, good nutritional practices,

stress management techniques and social support. However, since the

perceptions of an individual may be limited, changing all risky lifestyle

behaviours like smoking, alcohol abuse, which can result in a

deterioration of quality of life are regarded as health promotion needs

(Hogan, Mclellan & Bauman, 2000; Naidoo & Wills, 2000; Stuifbergen,

Seraphine & Greg, 2000;).

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4. Quality of life: The definitions and descriptions of quality of life include

both objective and subjective indicators of physical and psychological

phenomena (Stuifbergen & Rogers, 1997). Objective indicators

include income, living situations and physical functioning. On the other

hand, subjective evaluations of quality of life represent the individual’s

perception of important life domains and satisfaction with those domains.

Quality of life reflects an individual’s sense of well-being and satisfaction

with life (Stuifbergen, 1995).

5. Disability is defined as an umbrella term for impairment, activity limitation

and participation restriction. It denotes the negative aspects of interaction

between an individual who has a health condition and that individual’s

contextual factors which are environmental and personal factors (WHO,

2001b).

6. Stroke is defined as an abnormality of the brain characterized by

occlusion from either an embolus, thrombus, or cerebrovascular

haemorrhage or vasospasm, resulting in ischaemia of the brain tissues

normally perfused by the damaged vessels. The sequelae of a stroke

depends on the location and extent of ischaemia. Paralysis, weakness,

sensory change, speech defect, aphasia, or death may occur. Symptoms

remit somewhat after the first few days as brain swelling subsides. Also

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called cerebrovascular accident (CVA) (Mosby’s Medical, Nursing, and

Allied Health Dictionary, 2002).

7. Health needs include normative needs defined by experts or professionals

as well as the clients. They may also be comparative needs identified

when people or group areas fall short of particular established

standards (Naidoo & Wills, 2000).

8. Health is promoted by providing a decent standard of living such as good

labour conditions, education, means of rest and recreation.

Therefore, health is not simply the absence of disease: it is something

positive, a joyful attitude towards life, a cheerful acceptance of the

responsibilities that life puts upon the individual (Breslow, 1999).

1.8 Summary of the chapters Chapter one describes the basis of the current study. This includes a description

of the lifestyle patterns and behaviours of individuals with physical disabilities,

mainly those who have had a stroke. The researcher describes the impact of

disability with a particular focus on stroke. The manner in which poor lifestyle

behaviours may exacerbate the existing disability, and thus lead to further

deterioration of an individual’s life status, is also explored. The underlying

principle of the study highlights the need for health promotion intervention based

on the client’s health promotion needs.

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In chapter two, the literature reviewed highlights essential issues that need to be

focused on. A description of the physiological phenomenon, which is stroke and

information on the epidemiology of stroke internationally as well as locally are

given. The prevalence of disability internationally as well as in South Africa is

also discussed. Special reference is given to the prevalence of disability in the

Western Cape. The concept of health promotion and disability are also further

discussed in this chapter. The conceptual model of health promotion reviewed in

this chapter reveals the influence of contextual factors on health behaviours, and

the subsequent outcome of quality of life. The health promotion needs of

disabled individuals are also discussed. Finally, the use of between-method

triangulation adopted in the study methodology is reviewed.

In chapter three the study milieu, study population and sampling are described.

Furthermore, an attempt is made to explain essential methodological issues,

including methods of data collection and study procedure utilized. A self-

administered questionnaire survey and in-depth face-to-face interviews were

employed in data collection. Descriptive and interferential statistics were utilized

in quantitative data analysis. A series of qualitative data analysis consisted of

translations of interview quotations and field process notes. Then, precise

transcriptions of audiotape recordings and the discovery of strong themes that

ran through the data followed. Finally, qualitative textual data was compared to

numerical quantitative findings to qualify the process of between-method

triangulation utilized in the study.

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In chapter four, the results of the study are presented. Means, standard

deviations and percentages are used to present descriptive statistics while the

chi-square tests was used to test associations between certain variables.

In chapter five, the discussion centres on an attempt to interpret the current study

findings, and a comparison of the study results is made with similar studies. An

effort is made to discuss how the existing trends of participants’ poor lifestyle

behaviours could be reversed.

The final chapter entitled ‘Summary, Conclusions and Recommendations’,

summarizes, draws pertinent inferences from the research and proposes

suggestions for future action.

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Literature Review Health Promotion needs of Stroke Patients

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction This chapter begins with the definition of stroke and describes the physiology of

stroke. In addition to the incidence of stroke internationally as well as in South

Africa, the prevalence of disability worldwide and in South Africa with special

reference to the Western Cape, is also discussed. A number of health-

promoting behaviours and the concept of health promotion are reviewed, which

highlight self-care and encourage an active, self-sufficient approach towards

health. The numerous factors such as personal, environmental, cultural and

group factors which have an influence on the health behaviours of disabled

individuals are discussed. Stuifbergen’s conceptual model of health promotion

for people with disabilities is also reviewed. The numerous health promotion

needs of disabled individuals are discussed with reference to past literature on

the subject. The chapter ends with the significance of the use of between-

method triangulation that was utilized in the data collection.

2.2 Definition and cause of stroke A stroke is defined by the World Health Organisation (WHO) as ‘a clinical

syndrome characterized by rapidly developing clinical symptoms and/or signs of

focal and at times global (applied to patients in deep coma and to those with

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subarachnoid haemorrhage) loss of cerebral function, with symptoms lasting

more than 24 hours or leading to death, with no other apparent cause other than

that of vascular origin’ (WHO, 1989).

Therefore, any occlusion of the lumen by embolism or thrombus, rupture of a

vessel, any lesion or altered permeability of the vessel wall, and viscosity or other

change in the quality of the blood, will result in signs and symptoms of

neurological deficit (Victor & Ropper, 2001). The nerve cells in that part of the

brain deprived of blood cannot function, which sometimes results in total or

partial loss of consciousness. The brain is dependent on having a steady supply

of oxygen. Because there is no reserve supply of oxygen in the cerebral tissues,

cerebral metabolism cannot be sustained during periods of reduced or total loss

of cerebral blood flow. When the brain is completely deprived of oxygen, it

undergoes ischemic necrosis or infarction (Victor & Ropper, 2001). Such

changes within the brain can result in extensive damage (focal deficit) and occur

within 10 to 20 seconds. Irreversible damage can occur in the cerebral

hemispheres after 3 to 10 minutes (Sessler, 1981).

Ischemia, whether resulting in cerebral infarction (i.e., blockage), or resulting in

an intracranial hemorrhage, is one of the most frequent precipitating causes of a

stroke. The Committee of the National Institute of Neurological Disease and

Stroke of the National Institutes of Health classifies more than 50 different

diseases as potential predisposing risk factors of a stroke (Sessler, 1981).

According to Kasner & Gorelick (2004), risk factors include hypertension,

17


hyperlipidemia, cardiovascular problems, smoking, alcohol use, diabetes

mellitus, insulin resistance and metabolic syndrome, obesity,

hyperhomocyst(e)inemia, inflammation/infection, and illicit drug use and abuse.

Both infarction and ischemia result from an interruption in the flow of blood to the

brain and from tissue perfusion. A cerebral hemorrhage results from a ruptured

vessel which, because of the spurting of blood from the injured vessel, destroys

some of the nerve cells. A blood clot can also form around the area of spurting

blood.

Those parts of the brain that control the motor and sensory systems of the body,

that have been damaged because of the loss of their blood supply, are no longer

able to control these functions. The result is paralysis of or loss of some function

in these affected areas. These effects can be slight or severe, temporary or

permanent (Sessler, 1981).

Although death may occur within hours or days after the onset of a stroke, most

patients do survive for many years. Recovery depends on which brain cells have

been affected, how widespread the damage is, how fast the body can repair

itself, and whether other parts of the brain that have been less damaged can

compensate by taking over the functions of the severely damaged brain cells

(Victor & Ropper, 2001).

A stroke never affects all areas of the brain equally. Fortunately, most strokes

affect only a small area of the brain and result in the loss of only a few vital

18


functions. It is only when a stroke is so massive or when many areas of the brain

have been affected that the damage then becomes irreversible and there is

widespread paralysis and loss of vital functions (Sessler, 1981)

2.3 Epidemiology of strokes Stroke is a common and serious disorder. Each year there are approximately

750, 000 people in the United States who have a new or recurrent stroke and at

least 20 million worldwide who have had a stroke (Broderick, Brott & Kothari,

1998). Stroke is the third leading cause of death in America after heart disease

and cancer. One in every three deaths in the United Kingdom results from

stroke, and it is the single greatest cause of disability in the adult population

(Wolfe, 2000). Given that the incidence of stroke in the British population alone

is estimated to rise by as much as 30% over the next 20 years (Wolfe, 2000), it

represents a major and ongoing challenge for society.

In the Netherlands, approximately 27 000 people (~ 0.2% of the population)

suffer a stroke each year, and ageing of the population will cause this number to

increase by 30% in 2015 (Public Health Status & Forecasts, 1997). Presently,

one third of Dutch patients with a first-ever stroke die within 36 months, making

stroke the third leading cause of death in the Netherlands (Voorburg & Heerlen,

2001). About 60% survive with moderate or severe handicaps (Dutch Heart

Foundation, 1999). In 1999, stroke was responsible for 2.9% of the Netherlands

total health care costs, and for 6.0 % in the population aged 75 and over. Thus

19


stroke ranked second on the Netherlands list of most costly diseases for the

elderly, after dementia (National Institute of Public Health & the Environment,

2002).

Variations in mortality rates exist globally with more affluent developed countries

such as the United States, United Kingdom and the Netherlands, having lower

mortality rates than poorer developing countries such as Mauritius (Murray &

Lopez, 1997).

Strokes are next in importance to cardio vascular diseases in morbidity and

mortality in Mauritius. In 2001, strokes accounted for 15.6% of deaths registered

on the island. The incidence of stroke in Mauritius is one of the highest in the

world. Stroke contributes to 6 percent of the total burden of disease in men and

women in Mauritius. The last Non-Communicable Disease Survey carried out in

1997, revealed that 20% and 30% of the population aged 30 years and above

are diabetic and hypertensive respectively, with a further 40 % of the population

in the same age group being overweight. 42% of men and 3.3% of women are

smokers. The control of diabetes, hypertension, and other health-related

behaviours will go a long way towards reducing the incidence of strokes in

Mauritius (White Paper on Health Sector Development & Reform, 2002).

In South Africa, stroke is the third most frequent cause of all deaths reported in

the country and in 1990 accounted for 9,6 % of all reported deaths. Of all the

deaths reported in the age group 25-64 years, 7.45 % were due to stroke

20


(National Guideline on Stroke and Transient Ischaemic Attack Management,

2001).

The highest documented stroke rates are found in the Coloured and Indian

communities of South Africa, with age-standardised mortality rates (1984-1986)

of approximately 125-175 per 100 000 per annum. The lowest rates were found

in the White community at the rate of about 70 per 100 000 per annum. Stroke

mortality rates were similar in men and women in South Africa, but incidence is

approximately 30% higher in men than in women. Very few figures are available

for Black communities but are assumed to be much higher, a suggested figure of

300 per 100 000. What is known is that black patients present much younger

with stroke than white patients, the cause among black patients is mainly related

to hypertension and morbidity is higher in this group (Department of Health,

2001).

It is estimated that there are about 6 million hypertensive people, 7 million

smokers and 3-4 million diabetic patients in South Africa who are at risk for

having a stroke (Department of Health, 2001). Improved management of the

above risk factors, is key to reducing the stroke mortality figures in South Africa,

and to reduce the number of individuals living with disabilities as a result of

stroke.

21


2.4 Prevalence of disability

Disability is a global phenomenon of huge proportion, eliciting growing local,

national and international concern. A conservative global estimate of the

prevalence of disability, extrapolated from the findings of international surveys

suggests that a staggering 537 million people in the world suffer significant

disability (Bhagwanjee & Stewart, 1999). Stroke is an undisputed major cause of

disability (White & Johnstone, 2000). In the United States, of the 500 000

people who have a stroke, 300 000 are left disabled (Agency for Health Care

Policy & Research, 1995). Bonita, Broad & Beaglehole (1997), reports an

estimated disability prevalence in New Zealand of 4.6 per 1000 of the population

15 years and older. Recent estimates of the disability prevalence in South Africa

indicated an alarming population prevalence of 13% in 1995, with 5% of this

population being severely disabled (Bhagwanjee & Stewart, 1999).

According to the 1996 census, the prevalence rate for disability in the Western

Cape was 3.7%, which was lower than the national average of 6.6%. These

figures correlate with the findings (respectively 3.8% and 5.9%) of a study done

by the Community Agency for Social Enquiry (CASE) on commission of the

National Department of Health during 1997-1999, as cited in the Integrated

Provincial Disability Strategy (2002). Stroke is one of the commonest causes of

disability in South Africa (Department of health, 2001).

According to the Integrated Provincial Disability Strategy, there are estimated to

be more than 145 000 people with disabilities in the Western Cape alone

22


(Integrated Provincial Disability Strategy, 2002). Visual impairment is the

disability with the highest prevalence in the Province, followed by physical

disability. The distribution of disability in terms of types correlates with the

pattern at national level. The findings of the CASE study similarly indicates that

disabilities related to moving and seeing have the highest prevalence. A

significant percentage (20.8%) of persons with disabilities did not specify the

nature of their disability (Integrated Provincial Disability Strategy, 2002). It is not

known the extent to which stroke make up these numbers.

A stroke is no respecter of age or position in life. From the newborn infant to the

oldest citizen, no one is immune. According to the Integrated Provincial Disability

Strategy (2002), the age groups 25-29 and 30-34 represent the highest

percentages respectively 8.0% and 8.2% of the disabled people in the Province.

The distribution of the disabled population according to age is more or less

similar to the age distribution of the total population. The highest number (64

944) of people with disabilities in the Western Cape Province are from the

coloured population group, who are the largest population group in the Province

(Office of Premier, Western Cape, 2002). No specific data relating to the extent

of disability post-stroke is available in South Africa (Hale & Eales, 2001). This is

to be expected, as data relating to the prevalence and nature of disability in

South Africa are also seriously lacking (Office of Deputy President, Republic of

South Africa, 1997).

23


2.4.1 Disability Post-stroke It is important to note that stroke is a sudden event and not a progressive

disabling condition. The impacts of stroke therefore occur immediately and not

over a period of time (White & Johnstone, 2000; Wyller & Kirkevold, 1999).

The most common impacts that occur following stroke are impairments such as

impaired motor function, sensory deficits, abnormal tone, perceptual and

cognitive limitations, speech impairments and depression (Clarke, Black, Badley,

Lawrence & Williams, 1999; Duncan et al., 1997; Mayo et al., 1999;). According

to Clarke et al. (1999), the activity limitations that are experienced by stroke

clients are a decrease in mobility in the home and community, an inability to

return to previous employment as well a limited involvement in recreational and

social activities. Participation factors that are known to be affected are the social

interaction of the clients (Dowswell et al., 2000). In the qualitative study done

by Dowswell et al. (2000), the subjects expressed the view that social isolation

was not only due to the physical obstacles that limited their social functioning, but

also the client’s feelings of shame. These clients also felt that they could not

fulfill their prior roles and thus had no purpose. Emotional and behavioural

problems experienced by stroke survivors therefore also impact on their social

functioning and quality of life (Hostenbach, 2000). The quality of life of an

individual relates to the individual’s perceptions of his or her emotional, social

and physical well-being, and is said to encompass more than the sum of the

effects of the impairment, the activity limitation and the participation restriction

(Duncan et al., 1997). The impact of post-stroke disability is therefore vast and

24


strategies including intensive rehabilitation and health promotion are crucial to

improve the health prospects and functional independence of people with

disabilities (Rimmer, 1999).

2.5 Concept of health promotion and disability The Ottawa Charter has defined health promotion as ‘the process of enabling

people to increase control over, and to improve their health” (WHO, 1986). “To

reach a state of complete physical, mental and social well-being, an individual or

group must be able to identify and realize aspirations, to satisfy needs, and to

change or cope with the environment” (WHO, 1986).

The concept of health promotion emphasizes self-care rather than expert care

and promotes an active, independent attitude towards health care (Breslow,

1999; Smith, 2000). According to the WHO health promotion paradigm, society

should aim to create prerequisites for health in society and to enable people to

increase control over their lives and mobilize their internal resources. It focuses

on health and promotion of health rather than disease. Health promotion is a

process that facilitates the development of someone’s self and ability to act in a

social setting (Medin, Bendtsen & Ekberg, 2003). Health promotion programmes

have evolved from community action programmes which were based around

lifestyle risk factor modification (Nutbeam, Smith, Murphy & Catford, 1990). The

Kilkenny Health Programme in Ireland which ran from 1985-1991 (Shelley et al.,

1995) focused on instigating supportive changes of varying kinds which would

25


reach individuals who should alter their unfavourable health behaviours such as

smoking and poor eating habits. This would have an impact on risk factors

initially and ultimately on disease specific mortality and morbidity rates (Holman,

1997).

Programmes such as the Kilkenny Health Programme, that aim to encourage

health promotion within the disabled community showed beneficial risk factor

changes at follow-up compared with baseline in terms of the lifestyle risk factors

targeted, so that there were falls in the systolic blood pressure, cholesterol and

smoking practice (Shelley et al., 1995). Therefore by implementing programmes

which could provide access to knowledge and resources, to individuals with

physical disabilities, may result in such individuals being better empowered to

make the correct choices for health-promoting behaviours to sustain and

enhance their quality of life (Stuifbergen & Rogers, 1997).

A wider perspective of health promotion is the recognition of the health-promoting

role and responsibility of all health care professionals (Smith, 2000).

Consequently, people with life-long physically disabling conditions often face

challenges of promoting their health and maintaining their quality of life with little

help from health care rehabilitation professionals (Rimmer, 1999; Smith, 2000;

Stuifbergen & Rogers, 1997). A qualitative study undertaken by Stuifbergen and

Rogers (1997) found that numerous participants with chronic disabling conditions

created very satisfying lives for themselves, usually with very little assistance

26


from health care professionals. While some of the participants in the study had

received valuable health promotion advice that resulted in a positive impact on

their quality of life from health care professionals, virtually none of them indicated

that they had received any information from nurses. Many of the participants had

received no recommendations from any health care provider regarding health

promotion strategies and had been forced to adopt self-education strategies to

learn about their illness and how to cope with it on a day-to-day basis in an

attempt to maintain a satisfactory quality of life. Stuifbergen & Rogers (1997)

concluded that health care professionals, particularly neurologists, nurses and

physiotherapists need to be proactive in recommending health promotion

strategies to the disabled population. They also need to be aware of and

appreciate the tremendous potential they have for positively affecting the lives of

individuals with chronic disabling conditions by recommending and encouraging

quality of life-enhancing health promotion activities. According to Stuifbergen &

Rogers (1997), health promotion activities includes activities such as physical

exercise or activity, eating practices, seeking of social support and stress

management. Such health promotion activities are viewed as being essential to

the process of rehabilitation and maintaining an acceptable quality of life


Rehabilitation is the strategy used by health care professionals to address the

impairments, activity limitations, participation restrictions and changes in

quality of life the stroke patients experience (Integrated National Disability

27


Strategy, 1997). Health promoting actions for chronically ill patients such as

those with stroke are considered to be important components of the rehabilitation

process. Health-promoting actions include comprehensive rehabilitation

services, supporting the caregivers and providing the stroke patient with social

support as well as social networking. Comprehensive rehabilitation services

need to be made available to all stroke patients. These rehabilitation services

not only address the physical needs of the patient, but also their psychological

and emotional needs. Stroke patients require adequate medical treatment, but

they need more to cooperate effectively during and after treatment and to cope

with their social, practical and psychological problems. People need adequate,

consistent and clear information, emotional support and practical help and

opportunities to discuss openly their feelings and uncertainties. Health-promoting

actions include informing the stroke patient accurately about the condition and

how to control risk factors through behavioural change. Support programmes for

the caregivers of stroke patients should be developed and applied, to prevent

burn-out and to educate them on the different aspects of the patient’s condition.

Social supports are very important to all disabled individuals, and refer to the

interpersonal relationships that protect people from the negatives of stress

(Kessler, Price & Wortman, 1985). Social supports can be classified according to

whether they relate to structural or functional aspects of the relationship.

Structural aspects of the relationship include: living arrangements, frequency of

contact, participation in social activities like attending a stroke group, and

involvement in social networks. Functional aspects include: emotional support,

28


encouraging expression of feelings, provision of advice or information, provision

of material aid (Kessler et al., 1985). House (1981) classified supportive

behaviour from others in terms of four general classes: emotional, appraisal,

informational, and instrumental. Emotional support refers to feedback and

affirmation. Informational support includes suggestions, advice, and information

that one gets from others only. An example of informational support would be

when a physiotherapist educates a stroke patient and the caregivers on pressure

sores, and demonstrates how to regularly check the patient’s affected side for

their development. Instrumental support has to do with labor, money, and time

that one can obtain from those with whom one affiliates. Being able to rely on

family members and/or neighbours for a weekly lift to a stroke group would be an

example of instrumental support.

Health promotion emphasizes the importance of social integration and mutual

understanding in coping with the stress of life and illness. Including the family

and significant others in the treatment procedures are important steps in the

health promotion for chronically ill people (Badura & Kickbusch, 1991).

In order to understand health behaviours and health status, it is necessary to

look beyond social supports and to consider the broader social networks in which

supports may or may not take place. Mitchell (1969) defined social networks as

having three dimensions: structural, the interactional, and the functional. The

structural dimension refers to the size, density, and interconnectiveness of

29


specific linkages between individuals. An example would be the extent to which

people know one another (Mitchell & Trickett, 1980). The interactional dimension

is more concerned with the nature of the relationship, the quality of interactions,

and the degree of reciprocity of relationships to others. The functional

dimension is concerned with functions provided by various network numbers

such as individual policy makers, non-government institutions providing services

to stroke patient’s etc. Evidence suggests that the transmission of positive

values toward medical care (for example, the cessation of smoking) and the

sharing of health related knowledge is accomplished through social network

interaction (Coppatelli & Orleans, 1985). In this sense social networks provide

specific linkages that are used to interpret an individual’s behaviour and to

provide cues to preventative behaviour. Gravell, Zapka and Mamon (1985),

suggested that interventions must take the form of providing key network

members with pertinent health-promoting information in an effort to stimulate

informed discussion within social networks, thereby increasing the probability of

preventative health behaviours.

2.6 Factors that influence health behaviours Health behaviours are a part of one’s life-style, which is a broad concept

encompassing not only behaviours and attitudes, but an outlook of life. There

are numerous factors that can influence the development of a disabled person’s

30


life-style, and health behaviours can be grouped into four main categories:

environmental, cultural, group and personal factors (Gochman, 1988).

Environmental factors: Although there are several aspects of the physical

environment over which a person can sometimes exert some direct control and

choice (e.g. where they live and work), often such controlled choices are not

possible. There are many more aspects of the physical environment that are

influenced by public and organizational policies and policies over which we have

little direct personal control, e.g., air, water, noise, pesticides, pollutants, and

food preservatives (McKee, 1974; Milio, 1981). The quality of the physical

environment has both direct and in-direct effects on one’s health and influences

one’s health promoting behaviours.

As the speed of technology and industrialization has accelerated, environmental

problems such as pollution have become more numerous and complex. This has

an affect on the type and quality of the physical environment and will ultimately

have a direct effect on the nutritional environment, i.e., the kinds of foods

available and their cost. People will be less willing to participate in health

promoting behaviours such as eating a healthy diet, if the fruit and vegetables

needed to maintain such a diet are too expensive to afford. The physical

environment will also influence the type, availability, and accessibility of health

and social services. It might be expected that the more restrictive and hazardous

the physical environment, coupled with a feeling of little personal control to

31


change it, the more individual health promoting behaviours’ will be limited,

inflexible, and of low value.

Given certain physical conditions, behavioural options that influence health may

not be known or considered important, especially if such behaviours have no

immediate, observable effect (Gochman, 1988).

Cultural factors: Health behaviours are largely learned passively during the

process of socialization. Because healthy life-styles and behaviours are not

highly valued or systematically taught, unhealthy life-styles and behaviours that

are learned take substantial effort to modify (Maccoby & Farquhar, 1975).

Individuals are continually confronted with messages in the mass media

promoting unhealthy foods, alcoholic beverages, cigarettes etc. Unfortunately,

individuals find it easier to receive and process information selectively to confirm

the behaviour they have chosen to pursue, than to change that behaviour

(Gochman, 1988).

Group factors. Although there have been a few studies that have dealt directly

with health learning, it seems that a large amount of life-style and health and

illness behaviour is acquired in the family setting (Mechanic, 1963). Litman

(1974) found that parents, irrespective of the generation, were the most

frequently mentioned source of health attitudes and opinions, followed by the

spouse, health personnel, and the mass media. There also appears to be some

32


evidence that families’ use of medical care services may be related to factors

such as the individual’s education level and their concern over their own health

(Mechanic, 1963).

Fuchs (1974) has stated that the more education people have, the healthier they

tend to be. People with more education tend to come from families with more

money, who can afford better health care. Good education may lead to more

sensible work and living habits. Formal schooling may also increase self-

confidence and decrease stress. Fuchs therefore concluded that people

determine much of their health status and health behaviours by the way they live.

Personal factors: Personal lifestyle factors that relate to health behaviour include

beliefs about control, hardiness, and coping skills.

Beliefs are personally formed cognitive configurations that are often culturally

determined and shared. They are preexisting notions about reality that serve as

a perceptual ‘set’. People develop beliefs about health and the degree to which

they can influence their own health status. Beliefs about personal control have to

do with feelings of mastery and confidence. There are several models for

explaining the components of health beliefs, including personal control. One of

the best known models is the ‘health belief model’ (Gochman, 1988). The health

belief model (Becker, 1974) focuses on two related appraisal processes: the

threat of illness, and the behavioural response to that threat. Threat appraisal

involves consideration to both the individual’s perceived susceptibility to an

33


illness and its anticipated severity. Behavioural evaluation involves consideration

of the costs and benefits of engaging in behaviours likely to reduce the threat of

disease. In addition, the model suggests that health-related decisions are

triggered by environmental cues. Later versions of the model (Becker, 1974)

added a fourth dimension, the individual’s motivation or ‘readiness to be

concerned about health matters’, although this has rarely been addressed by

researchers (Conner & Norman, 1996). Although each factor is considered of

importance in any decision-making process, no clear operationalization of how

the constructs combine to result in a final decision has been developed (Lewis,

1994; Ronis & Harel, 1989).

Control is another factor that can relate to the health behaviour of an individual.

Control refers to the real or perceived ability to determine outcomes of an event.

When an individual’s behaviour is perceived as causally linked to outcomes,

perceptions of control are possible. When the outcomes cannot be tied to

behaviour, it is more difficult to believe that one is in control (Gatchel & Baum,

1983). Control has dealt with two main issues: (1) the effects of believing that

one has control and that outcomes are contingent on responses and (2) the

effects of believing that outcomes are not contingent on behaviour and therefore

not controllable. The first has been concerned most directly with the mediating

effects of perceived control on response to aversive stimulation and stress. The

second has been concerned with learned helplessness and debilitating effects of

believing that one cannot control what happens. Research implies that when

34


faced with health problems, disabled individuals who have an internal locus of

control appear to engage in generally more adaptive responses than externally

controlled individuals. These range from preventative health measures through

remedial strategies when illness occurs.

Kobasa, Maddi & Kahn (1982) examined ‘hardiness’ as a personality construct

comprised of three characteristics: commitment, the tendency to appraise

demands as challenging rather than threatening, and having a sense of control

over one’s fate. It was found that people characterized as ‘hardy’ were less

prone to stress and had a positive attitude towards their health and practiced

good health behaviours’ despite their level of disability.

A disabled individual’s perceptions, in addition to the numerous environmental,

cultural, group, and personal factors previously discussed, can influence the

development of health behaviour. Individual’s perception of vunerability or

susceptibility, their perception of benefits and costs, and their perceptions and

assessments of competing needs all influence, in various ways, health actions or

inactions (Feuerstein, Labbè & Kuczmierczyk, 1986). In this regard, the conflict

theory model of personal decision-making, unlike the health belief model,

attempts to specify the conditions under which individuals will give priority to

health matters and seek out medical information about the consequences of

alternative courses of action. Jannis & Mann (1977) delineated five stages

individuals go through in order to arrive at a stable decision. These stages were

identified by observing individuals who made health decisions they subsequently

35


carried out successfully; these included giving up smoking and following a

regular exercise regime. Stage 1 takes the form of an event or communication

that conveys a threat or opportunity. The individual must either ignore or repeat

the challenge or accept it and progress to the next stage of decision making. In

stage 2, the individual carefully considers the goals relevant to the decision and

looks for alternatives. Throughout stage 3, the individual evaluates the proposed

cost of each alternative. Stage 4 sees the decision maker increasingly

committed to a course of action. Finally, in stage 5, the decision maker discards

new challenges and continues with implementing the decision. Janis & Mann

(1977) agree that only when an individual’s pattern is vigilant will the person be

able to make a rational choice based on weighing the benefits or costs of taking

an action.

The perception and assessment of personal risk is an important aspect of life-

style and health behaviour. The decision on whether or not to take an action

depends on the kind of information received and also on the state in which the

recipient of the information is at the time. Baric (1969) described four different

states of health (healthy, at risk, convalescent, and ill) and noted that people in

each of these states will need a different kind of health information. Baric

explained that a healthy person who becomes aware of a health threat, will

undergo a process similar to that of acquiring a sick role. For Kasl & Cobb

(1966) sick role behaviour denotes those actions, undertaken by persons who

have already been designated as being sick or disabled, either by others or

themselves. Such behaviours include, but are not limited to, acceptance of a

36


medically prescribed regimen; limitation of activity and of personal, family and

social responsibilities; and actions related to recovery and rehabilitation. Baric

(1969) emphasized the limitations of efforts to modify health behaviour if

intervention is focused on the sick role or at the point at which a person has

already made a health decision based on a perception and assessment of risk.

Finally, a person’s perception of risk, possible benefits, and assessment of need,

relate to an overall attitude of responsibility for one’s health. The health care

system provides sophisticated, technological services for complex physical

disease; yet it is not as effective in providing preventative services. The public

have high expectations of medicine’s ability to cure and rehabilitate. These

expectations are reinforced by the mass media and the publicity given to

technological advances in health care. Providers of health services have helped

to create high expectations and a dependency on technology to cure disease.

This results in an attitude that one does not need to assume personal

responsibility for ones health. An individual’s attitude toward responsibility for

health is learned at an early age, modified and reinforced by the media, and often

is unchangeable until a health crisis forces a reevaluation of attitude, behaviour,

and life-style. A life-threatening event such as a stroke, is often a potent modifier

of priorities and attitudes toward life (Cousins, 1979).

37


2.7 Conceptual model of health promotion for people with disabilities The general conceptual model used in this study represents a synthesis of

findings from the review of the literature. Stuifbergen (1995) proposed a process

model comprising of factors that influence health-promoting behaviours and thus

quality of life. Health-promoting behaviours are those personal attributes such as

beliefs, expectations, motives, values, perceptions, and other cognitive elements;

personality characteristicts, including affective and emotional states and traits;

and overt behaviour patterns, actions and habits that relate to health

maintenance, to health restoration and to health improvement (Gochman, 1988).

An improvement in one’s health status, will subsequently have positive outcomes

for an individual’s sense of well-being and satisfaction with their quality of life

(Stuifbergen, 1995). Quality of life can be determined objectively by an

individual’s standard of living situation, as well as the income and level of

physical functioning. Subjective evaluations of quality of life represent the

individual’s perception of important life domains and satisfaction with such

domains (Stuifbergen, 1995). Stuifbergen’s model proposed four antecedent

factors that influence health-promoting behaviours, namely demographic and

disability-related factors, resources, barriers and perceptual factors. However,

the Stuifbergen (1995) model does not indicate the relationship between

demographic and individual disability-related characteristics with other

antecedent factors, such as resources, barriers and perceptual factors.

38


Figure 2.1, illustrates a three-stage Conceptual Model proposed by Stuifbergen

and Rogers (1997). The figure indicates the direction of the predicted

relationship between specified antecedent factors and health-promoting

behaviours, all of which influence the outcome of quality of life. The model

specified the influence of demographic and individual disability-related

characteristics on other antecedent factors, health-promoting behaviours, and on

the outcome of quality of life.

39


Figure 2.1: Conceptual Model of Health Promotion and Quality of life for people

with permanent physical disabling conditions. Source: Adapted from Stuifbergen

& Rogers, 1997.

CONTEXTUAL FACTORS

Demographic and Disability characteristics

Barriers

Resources

Perceptual

Factors

Health-promoting

behaviours Quality of life

Stage 1 Antecedents

Stage 2 Health Behaviours

Stage 3 Outcomes

.

Contextual factors are visually represented as influences on previous

circumstances called antecedents, mediating health behaviours, and quality of

life outcomes. Antecedents include the concepts of barriers, resources and

perceptual factors, which serve as precursors to the next stage 2. The selection

40


and use of health-promoting behaviours in stage 2 act as a mediating influence

between the antecedents of stage 1 and the outcome of quality of life in stage 3.

In this model, quality of life is viewed subjectively as the individual’s satisfaction

with the domains of life perceived as being most important (Stuifbergen

Seraphine & Greg, 2000; Stuifbergen & Rogers, 1997; Stuifbergen & Becker,

1994).

2.7.1 Contextual factors Contextual factors include individual (e.g. age, gender, expectation of outcome,

motivation levels) and disability-related characteristics (e.g. severity of disability,

lesion location in the brain) that may influence, directly or indirectly, health-

promoting behaviors and quality of life (Rice-Oxley & Turner-Stokes, 1999;

Stuifbergen & Rogers, 1997;).

Gender specific societal processes have been shown to influence the health

behaviour of individuals. An example of the impact of social mores on health-

related behaviour can be found in studies of participation of exercise

programmes. Here, low participation rates for women are frequently ascribed to

family responsibilities and joint work-home responsibilities and the societal norms

which support such behavioural choices (Green, Hebron & Woodward, 1986).

Reddy, Fleming & Adesso (1992) found that men behave differently to women

and in general are more likely to be overweight, smoke more frequently, eat less

healthily, and drink alcohol more heavily than women. The place one occupies in

41


society therefore can impact substantially on ones health and health-promoting

behaviours.

The motivational level of an individual will also have an influence on their health-

promoting behaviours and quality of life. The World Health Organization’s

International Classification of Functioning and Disability defines motivation as a

global mental function (a conscious or unconscious drive), that produces the

incentive to act (World Health Organisation, 1999). Essential components of the

classification are those contextual conditions, such as personal and

environmental factors, that interact with body function, activity, and participation.

Thus motivation to engage in a health-promoting behaviour, may be influenced

by both personal factors (such as age, gender, personality, educational and

social background, experience, coping capacity, health status, and lifestyle) and

environmental factors, which together shape the physical, social, and attitudinal

context for rehabilitation and hence improving one’s quality of life (Holmqvist &

von Koch, 2001).

Health-promoting behaviours and quality of life may be dramatically influenced by

disability-related characteristics. In a recent study by Ivey, Macko, Ryan &

Hafer-Macko (2005), stroke patients were found to have profound cardiovascular

and muscular deconditioning. The metabolic fitness levels were discovered to be

approximately half of those found in age-matched sedentary controls. Physical

deconditioning, along with elevated energy demands of hemiparetic gait, define a

detrimental combination termed diminished physiological fitness reserve, that can

42


greatly limit performance of activities of daily living and the ability of the patient to

partake in health-promoting activities and behaviours.

Disability related characteristics such as the severity of the stroke and the lesion

location of the stroke have also been found to influence patients’ quality of life.

Few studies, however, have focused on the relationship between types of stroke

and lesion locations and patient’s quality of life. In a 4-year follow-up study,

Niemi, Laaksonen, Kotila & Waltimo (1988) found that patients with either a right

or left hemisphere lesion had more frequently evidenced quality of life

deterioration than patients with no localizable or brain stem lesions. Poststroke

deterioration in quality of life manifested primarily in basic activities such as body

self-care, ability to communicate, and eating (De Haan, Limburg, Van der

Meulen, Jacobs & Aaronson, 1995). De Haan et al., (1995) found that with the

exception of the ability to communicate, the quality of life profiles of patients with

lesions in the left hemisphere were slightly better compared with those of patients

with lesions in the right hemisphere. In comparison with patients who suffer from

lacunar infarcts, patients with larger supratentorial strokes (both infarcts and

hemorrhages) showed a significant deterioration in practically all life domains

with the exception of emotional distress. Quality of life, however, was unrelated

to the type of (sub) cortical lesion. Although patients with supratentorial

hemorrhages had suffered more severe strokes, resulting in higher rates of

impaired consciousness at stroke onset and poststroke mortality, they did not

evidence more quality of life impairment than survivors of supratentorial strokes

(de Haan et al., 1995). Similar patterns of recurrence and functional outcome for

43


survivors of hemorrhagic versus ischemic stroke have been reported by Franke,

van Swieten, Algra & van Gijn (1992).

2.7.2 Antecedent factors Antecedent factors include the barriers, resources, and perceptual factors that

influence an individual to choose to engage in health-promoting behaviors.

Barriers, defined as perceptions regarding the unavailability, inconvenience, or

difficulty of a particular health-promoting option, can be related to participation in

exercise programs and self-examination of the skin on the affected side for

pressure sores (Stuifbergen, Becker & Sands, 1990). They can also be primary

prevention of behaviors such as a sedentary lifestyle, nutrition of high fat and low

fibre content, exercise, use of alcohol or smoking and skin care (Stuifbergen &

Rogers, 1997).

A variety of resources including income and social support, are related to the

selection and use of health-promoting behaviors and health outcomes

(Stuifbergen et al., 2000). Tangible resources have been related to outcomes of

health behaviors including functional disability, adjustment, depression, and

quality of life (Schoppen et al., 2001). Various perceptual factors including

specific self-efficacy for health practices and perceived demands of illness, have

been reported to influence the likelihood of engaging in health promotion

behaviors (Stuifbergen & Rogers, 1997). Self-efficacy, defined as beliefs about

one’s ability to successfully perform specific health behaviours, has been

44


consistently identified as a significant predictor of health-promoting behaviours

for a variety of groups, including people with disabilities and with stroke (Becker,

Stuifbergen, Ingalsbe & Sands, 1989; Stuifbergen, 1995; Stuifbergen & Becker,

1994; Strecher, de Vellis, Becker & Rosenstock, 1986). The demands of illness

are subjective judgements about the difficulties, problems, or challenges inherent

in day-to-day living with a chronic illness. These demands encompass the direct

effects of a disease, personal disruption occurring as a consequence of illness,

and environmental transaction necessitated by the illness or disability

(Haberman, Woods & Packard, 1990). Descriptive studies of chronically ill

individuals, including stroke patients, have related the increasing severity of

illness (operationalized as increasing physical dependence, functional limitations,

development of secondary complications, and perceived severity of illness) to

severe restrictions in recreation and leisure activities, limitations in instrumental

and nurturant roles for homemakers, and reduced labor-market activity and

income (McSweeney, Grant, Heaton, Adams & Timms, 1982; Paringer, 1983;

Resine, Goodenow & Grady, 1987).

The impact of environmental factors for example, the effect of being in hospital

on the health-promotion behaviours of patients with stroke, including their

initiative and autonomy, is not well understood. Yet the low level of activity

initiated by stroke patients when they are in hospital (Ada, Mackey, Heard &

Adams, 1999; Lincoln, Willis, Phillips, Juby & Berman, 1996; Newall, Wood,

Langton Hewer & Tinson, 1997), and the disempowering nature of their role as

45


patients (Cant, 1997), suggest that closer attention needs to be paid to

environmental factors in rehabilitation (Holmqvist & von Koch, 2001). In a recent

study on the environmental factors in stroke rehabilitation, clear differences in

both patient’s and therapist’s behaviour were noted, when rehabilitation sessions

in patients’ homes or a community setting were compared with those in hospital

(Von Koch, Wottrich & Holmqvist, 1998). Patients that were not undergoing

rehabilitation in a hospital setting took the initiative and expressed their goals

more often. Therefore rehabilitation at a community setting, such as a

community health centre or the patient’s home, seems to empower patients

(Holmqvist & Von Koch, 2001). Patient’s who feel empowered over their stroke

and subsequent disability, are more likely to engage in health-promoting

behaviours and actions than those stroke patients with low levels of motivation

and a feeling of helplessness about their condition.

2.7.3 Health-promoting behaviors

These constitute stage two of the model, and include ongoing behavioral,

cognitive and emotional activities engaged in to promote health and well-being.

Physical exercise, nutritional strategies, lifestyle adjustment, maintaining a

positive attitude, health responsibility behaviours and seeking and receiving

interpersonal support constitute the six broad categories that have been

identified. A large majority of disabled people, including those who have had a

stroke, regard physical activity as consisting of self-initiated physical exercise,

including activities of daily living, as well as structured exercise programs such as

46


stroke groups (Stuifbergen & Rogers, 1997). In Stuifbergen and Roger’s

research on health promotion for persons with chronic disabling conditions, 95%

of participants discussed the importance of physical activity in their daily lives,

although many viewed their housework or other activities of daily living, such as

walking around the house, as the primary component of their physical activity.

The level of physical activity also varied according to the level of disability

(Stuifbergen & Rogers, 1997). Therefore, whilst a very disabled stroke patient

may be extremely pleased to accomplish a few very assisted steps twice a week

with the assistance of a physiotherapist, other less disabled stroke patients may

be participating in exercise programmes on a daily basis.

A good nutritional strategy is another important health-promoting behaviour for all

individuals who have had a stroke. Most of the disabled participants in

Stuifbergen and Roger’s study (1997) mentioned the importance of a well-

balanced diet, low-fat meals, and high fiber intake. Several participants also

emphasized the scheduling of meals to avoid low blood sugar or mid afternoon

‘slumps’.

Lifestyle adjustment includes efforts to structure demands and activities to allow

more time for valued activities. It has been found that lifestyle adjustment in

disabled individuals is usually required to engage in other health promotion

practices, particularly exercise and physical activity (Stuifbergen & Rogers,

1997). Lifestyle adjustments are commonly made by disabled individuals as a

result of their chronic condition and can include factors such as: learning limits,

47


monitoring, prioritizing and pacing, balancing rest and activity, choosing what one

will and will not do and avoiding heat. Regarding ‘learning limits’ individuals who

have had a stroke need to know their limits and do everything they can possibly

do within such limits. ‘Monitoring’ is closely related to ‘learning limits’. For

individuals who have had a stroke, limits may vary from day to day or from one

time of the day to another (Stuifbergen & Rogers, 1997). ‘Prioritizing and pacing’

includes undertaking important activities in the morning (such as exercising,

doing chores around the house) when energy stores are at the highest. Disabled

individuals need to pace themselves with all activities of daily living, and learn

how to fit their disability into their schedule, and not their schedule into the

disability. ‘Balancing rest and activity’ is another lifestyle adjustment that is

important to disabled individuals. Whether it be taking an afternoon nap or

getting an adequate, restful nighttime sleep, many disabled individuals

mentioned these as being the prerequisites for making it through each day

without negative sequelae (Stuifbergen & Rogers, 1997). Another lifestyle

adjustment is ‘choosing what one will and will not do’. An example is when

housewives who have had strokes face difficult decisions about what they can

and can not do in the home, such as cooking for the family every night, doing all

the housework, lifting heavy loads of laundry etc. ‘Maintaining a positive attitude’

is recognized as being another important health promotion strategy. Stuifbergen

& Rogers (1997) found that numerous disabled individuals strived to maintain a

positive attitude towards their condition and that this was the single most

important health promotion strategy they practiced. ‘Health responsibility

48


behaviours’ include efforts to seek information about stroke and general health

promotion. This includes regular check-ups and preventive screening with their

primary physician, consultations with nutritionists, psychologists,

physiotherapists, and others in an effort to maximize their health. Many disabled

individuals also attempted to avoid harm by not smoking, avoiding alcohol, and

reducing or eliminating caffeine intake (Stuifbergen & Rogers, 1997). ‘Seeking

and receiving interpersonal support’ is another important health-promoting

behaviour. In Stuifbergen and Roger’s study, numerous disabled individuals

indicated that it had been or still was very difficult to ask for help, but there was a

realization that help in many forms was essential to ensure their continued

functioning at the highest possible level. Numerous disabled individuals shared

the extreme importance that support groups play in their lives. Stroke groups not

only provide the individuals with an opportunity to get out of the house and

interact with other people, but also encourage physical exercise.

The realization that they were not alone in their problems has been identified as

a very important turning point in the emotional well-being of certain disabled

individuals (Stuifbergen & Rogers, 1997).

Selected studies document that disabled people desire and choose health-

promoting behaviors. The frequency of engaging in such health-promoting

behaviors has been associated with perceived quality of life (Stuifbergen, 1995;

Gulick, 1991).

49


2.7.4 Quality of life outcomes

The quality of life outcome in this model is assessed by the measure of the

functional status (Stuifbergen & Roberts, 1997). Most assessments however,

rely on the assumption that a decrease in functioning is analogous to a decrease

in quality of life (Stuifbergen et al., 1990). Therefore, these measures do not

consider the significance attributed to exact domains of life, such as physical

functioning (Stuifbergen et al., 2000). Objective indicators such as income, living

situations, and physical functioning are commonly used as measures of quality of

life. However, such measures fail to indicate how individuals actually perceive

their lives. In contrast, subjective evaluations of quality of life represent

individuals’ perception of important life domains and satisfaction with the

domains they judge as critical to their quality of life (Oleson, 1990; Stuifbergen &

Rogers, 1997; Stuifbergen, 1995).

Although interest in quality of life is high, few researchers have asked people with

chronic and disabling conditions to define the important domains that constitute

quality of life (Burckhardt, Woods, Schultz & Ziebarth, 1989). In a study

conducted by Bostick (1977), groups of people with and without disabilities had

similar responses when asked to describe the domains of quality of life. In a

study of adults with chronic illnesses such as stroke, independence (being able

to do for oneself) was the one theme generated in verbal responses that could

not be placed within the domains of the Flanagan Quality of Life Scale

(Burckhardt et al., 1989). Results of studies conducted with disabled populations

50


have suggested that contact with people without chronic conditions and

perceived support from family and friends are related to better psychological

adaptation (Maybury & Brewin, 1984; McIvor, Riklan & Reznikoff, 1984;

Wineman, 1990). Certain studies conducted on individuals with chronic

conditions, have identified linkages between quality of life and mastery, fatigue,

self-help, self-esteem, and perceived support (Braden, 1990; Burckhurdt, 1985;

Moody, McCormick & Williams, 1991).

People living with stroke must therefore manage a wide variety of disease-

related, intrapersonal, and environmental demands to maintain their quality of

life. Engaging in health-promoting behaviours is one strategy recommended to

manage disease symptoms and enhance quality of life (Stuifbergen & Rogers,

1997).

2.8 Involvement in health-promoting behaviours

In his model of health promotion for people with disabilities, Stuifbergen, Gordon

& Clark (1998) identifies certain factors that influence the disabled person’s

ability to engage in health-promoting behaviors. This entails participation in

activities designed to enhance the quality of life and well-being while refraining

from risk lifestyle behaviours, which often results in a deterioration of health.

Stuifbergen et al. (2000) emphasizes that participation in physical activity, stress

management techniques and social support are amongst the activities that

enhance an individuals well-being and quality of life. Futhermore, a number of

51


studies have highlighted the need to abstain from risky health behaviours such

as tobacco smoking or poor nutritional habits for physically disabled individuals in

particular, as well as the general population (Hogan et al., 2000; Steele et al.,

1997; Stewart, 1987;). The practice of health-enhancing behaviours is

undoubtedly critical for people with physical disabilities, however involvement in

health promoting activities for this vunerable group may be far from reality.

Health care professionals have clearly indicated that maintaining a suitable

physically active lifestyle has a profound effect on all-cause morality rates

(Cooper et al., 1999; Kalies, 2000; Rimmer, Rubin & Braddock, 2000).

Furthermore, physical activity can reduce overall mortality rates from

cardiovascular, pulmonary, metabolic and neuromuscular disease. It also

reduces the development of several different types of cancers, non-insulin-

dependent diabetes mellitus, hypertension, osteoarthritis, osteoporosis and

obesity (Cooper et al., 1999; Davis, 2000; Rimmer et al., 2000; Vuori, Oja &

Stahl, 1996;). Vuori et al. (1996) further states that there are also short-term

beneficial effects on psychological stress, depression, anxiety, mood and the

general psychological well-being. Surprisingly, some studies have also noted

that the level of health risk resulting from inactivity is similar to that resulting from

smoking (Cooper et al., 1999; Davis, 2000;). Despite these numerous benefits,

Rimmer (1999) is doubtful that the lives of the most physically disabled people

constitute daily habitual physical activity patterns.

52


The use of resources for health promotion may be expensive especially for the

less developed countries such as South Africa. However, involvement in health-

enhancing behaviours definitely far outweighs the current situations in which

policy makers use resources mainly for expensive medical care after certain

complications are irreversible. The time has come for resources to be used for

the promotion of health-enhancing behaviours. Even for developed countries like

the United States of America, it is crucial to shift not only from disability

prevention but also more importantly to the prevention of secondary conditions

(Rimmer, Braddock & Pitetti, 1996). Strategic programmes have been adapted

since 1996 by the European Union, for the promotion of health-enhancing

physical activity (Vuori et al., 1996). Despite this, much remains to be realized

for special considerations of target groups such as the physically disabled and

the elderly.

Despite the meager achievements to promote health-promoting behaviours, their

benefits are extensive. For example, recreational activities and sports increase

integration of physically disabled people back into society, and thus enhance

their quality of life. Studies on health-related behaviours and their effects on

quality of life have commended the need for involvement in other behaviours

such as access to relevant information about stroke and even stress

management techniques (Cooper et al., 1999; Rimmer et al., 2000; Stuifbergen

et al., 2000; Stuifbergen & Rogers, 1997).

53


Selected studies document that disabled people desire and choose health-

promoting behaviours such as participation in recreational activities, as

participation in such behaviours ultimately leads to an improved quality of life


Such lifestyle behaviour is significant to improve physical fitness as well as

sociability and self-confidence that can lead to a full satisfying health status

(Legro, Reiber, Czerniecki & Sangeorzan, 2001). A physically active lifestyle,

also decreases morbidity rates among all individuals, particularly those who are

already limited by a primary disability (Cooper et al., 1999; Melzer, Yekutiel &

Sukenik, 2001). Although health promotion strategies have not characteristically

been components of most rehabilitation programs (Lanig, Chase, Butt, Hulse &

Johnson, 1996), it is becoming increasingly obvious that the enhancement of

health-promoting behaviours should be a priority for programs serving people

with strokes (Stuifbergen & Rogers, 1997).

Therefore, adequate rehabilitation of stroke patients by health care professionals

is essential, as it is aimed at reducing the effects of the stroke on the individual in

an attempt to regain the previous level of functioning of the person and hence

improve their quality of life (Reddy & Reddy, 1997; WHO, 1994; Wressle, Öberg

& Henriksson, 1999).

Physically disabled individuals have not been sufficiently empowered to

participate in activities that prevent development of secondary conditions and

54


complications. Stuifbergen and Rogers (1997) supported this argument noting

that generally people with physical disabilities have been left to manage their

lives with little help from health care professionals.

Studies on health-related behaviours and their effects on quality of life have

commended the need for involvement in other behaviours such as access to

relevant information and stress management techniques to sufficiently empower

the disabled (Cooper et al., 1999; Rimmer et al., 2000; Stuifbergen et al., 2000;

Stuifbergen & Rogers, 1997).

Among many people with disabilities, there is a belief that the emphasis in health

care has been directed at the primary prevention of disability rather than at the

prevention or reduction of secondary health conditions (Patrick, 1997).

Undoubtedly, physically disabled individuals have not been sufficiently

empowered to participate in activities that prevent development of secondary

complications. Studies have advocated collective efforts to improve the lives of

people with physical disabilities through health-enhancing behaviours (Cooper et

al., 1999; Rimmer et al., 1996; Stuifbergen et al., 2000). The strategy is to

empower people with physical disabilities to take control of their lives by

motivating them to engage in healthy lifestyle behaviours (Breslow, 1999; Davis,

2000; Kalies, 2000).

Health behaviour is one of the fastest growing areas in health promotion

(Vollrath, Knoch & Cassano, 1999), and more concrete efforts in this field of

interest for both clients and professionals need to be attained. The

55


transformation of health behaviour needs to include topics related to living a

physically active lifestyle, stress management, the cessation of smoking and

coping strategies (Cooper et al., 1999). In order to do this, a number of issues

need to be considered in planning intervention strategies. Issues to be targeted

in health promotion interventions should consider a variety of factors.

Stuifbergen and Rogers (1997) noted that these factors consisted of resources

such as social support and income, transportation and socio-economical status,

all of which are related to health promotion behaviours. Such factors positively

influence the selection and use of health-promoting behaviours and health

outcomes. However, it is important to consider barriers that prevent access to

health promotion services for the prevention of further disability. Such barriers

include inadequate facilities, lack of appropriate transportation, lack of support,

inadequate resources and poor information about the available facilities (Smith,

2000; Stuifbergen, 1995).

Barriers can also include intrapersonal, interpersonal and environmental factors

that inhibit selection or use of health-promoting behaviours.

2.9 Health promotion needs of the physically disabled Various studies identify a number of health promotion needs of people with

physical disabilities (Dean, Fox & Jensen, 1985; Edwards, 1996; Forero,

Bauman, Young, Booth & Nutbeam, 1996; Hogan et al., 2000; Zola, 1982). The

results of a survey conducted by Marshall, Johnson, Martin, Saravanabhavan

56


and Bradford (1992) to determine the needs of urban American Indians with

disabilities, revealed the need for service providers to be more responsive to the

advocacy needs of people with disabilities. Only a third of the population

surveyed reported being satisfied with advocacy efforts in the community. While

the advocacy needs of people with disabilities were important concerns in the

Marshall et al. (1992) survey, Kent, Chandler and Barnes (2000) found that

factors such as the presence of informal family networks, access to services,

access to employment and access to transport, were regarded as important in

reducing the disadvantage and isolation suffered by people with disabilities in the

United Kingdom.

To add to the understanding of quantitative data about health outcomes,

Hildebrandt (1999) gathered and analysed qualitative data concerning the

perceptions of vunerable people regarding their health needs and barriers to

health care. The term ‘vunerable people’ was used to refer to persons in the

United States that were disadvantaged because of poverty, living in high-risk

environments, social bias and having a disability. Central problems identified in

the study included access, self-care, consumer/provider attitudes and

networking. In another qualitative study by Turmusani (1999), to investigate the

economic situation of people with disabilities in Jordan, focus groups were used

to gain insight into the perceived economic needs of people with disabilities and

to highlight their perceptions of services designed to address their needs. The

research concluded that awareness of economic need such as a need for

57


employment, is a key element in changing attitudes towards people with

disabilities.

In South Africa, the needs of people with disabilities have been investigated and

described by several authors. The aim of a study done by Meyer and Moagi

(2000) in the North West Province, was to determine what the needs of mothers

who had children with disabilities were. The needs identified by the mothers

included a day centre for their children, education and skills training in handling

and training children, a support group to share problems, income generation

activities, and resources for the day center, including transport.

Another South African study done by McLaren, Philpott and Mdunyelwa (2000) in

Kwazulu Natal, showed that people with disabilities experience emotional,

spiritual, attitudinal, financial and physical barriers as they are not generally

accepted in the community as persons who have their own rights and feelings.

This leads to poor self-esteem and disempowerment on the part of the person

with a disability as they lack the resources that will enable them to take control of

their lives. Lorenzo (2001) reported similar findings in a participatory action

research study in Khayelitsha, South Africa. The study focused on the needs of

women with disabilities. Analysis of the women’s stories revealed their need for

identity, emotional support and protection. The study further revealed that if

disabled women can be assisted to become active, competent participants in

their own development, they will be able to overcome feelings of isolation and

58


dependency. Lorenzo also asserts that the identification and removal of barriers

to the social integration and economic independence of women with disabilities

will have a positive influence on their families, as well as the communities in

which they live.

Mutimura (2001) discovered that individuals with lower limb amputation in

Rwanda, have a number of health promotion needs, mainly resulting from risky

health behaviours. The majority lived sedentary lifestyles, participating in less

physical activity or exercise. Numerous participants were involved in substance

usage like tobacco use, drug abuse or alcohol consumption. In addition,

participants were found to be vunerable to emotional disorders due to low

psycho-social status and self-perception. This study concluded that the impact of

such lifestyle behaviours was detrimental to the participants’ health status. If no

health promotion programmes specifically targeted at the needs of the

participants’ were put in place, this would result in poor quality of rehabilitation

services. Consequently, this would increase morbidity and mortality rates,

leading to an increase in the healthcare costs of a country whose health budget

is already overstrained.

By identifying the health promotion needs of stroke patients accessing

community health centres in the Metropole region of the Western Cape, specific

interventions addressing these needs can be implemented. A variety of

strategies can be implemented soon after the diagnosis of stroke, as a means to

59


improve the patient’s health and to diminish their struggle to achieve and

maintain a satisfactory quality of life.

2.10 The use of between-methods triangulation The use of between- methods triangulation was employed in the collection of

data. Between-methods triangulation may be defined as the combination of the

research strategies using qualitative and quantitative methods (Rees & Bath,

2001). It can occur simultaneously or sequentially (Maher, Kinne & Parteick,

1999; Rees & Bath, 2001). In this study, simultaneous triangulation of methods

was utilized.

According to Begley (1996), between-methods triangulation is becoming an

increasingly popular methodology in research. It offers greater confidence in the

validity of the study findings. The method also improves confirmation of the

results and yields a more complete representation of the topic of investigation,

that is to say completeness (Morse, 1991). Although several researchers have

suggested that the fundamental aim of between-methods triangulation is one of

confirmation (Begley, 1996; Bradley, 1995; Morse, 1991), others argue that

triangulation could serve the function of completeness (Begley, 1996; Nolan &

Behi, 1995; Rees & Bath, 2001). In the current study, between-methods

triangulation was utilized for the purpose of both completeness and confirmation

of the study findings.

60


It was important to employ two methods since they complement one another.

This methodological approach, called triangulation of methods combines

quantitative and qualitative styles of research that provide a more comprehensive

picture of the topic of enquiry than that supplied by either method alone (Avis,

1995). The use of both methods produces results and conclusions that are more

dependable (Avis, 1995; Rees & Bath, 2001). Rees and Bath (2001) used the

triangulation method in the analysis of the information sources given by partners

of women with breast cancer. By combining both quantitative and qualitative

data, the authors found that the study possessed a good convergent validity that

resulted in further confirmation of the study findings.

For the quantitative research methodology, a survey questionnaire was used to

collect data on the number of stroke patients involved in various health-related

behaviours, such as physical inactivity, smoking, alcohol abuse etc. In addition,

health promotion needs were also identified from the questionnaire. However,

the exact reasons for involvement in particular health risk behaviours, such as

smoking, poor nutritional status etc. was only clarified in face-to face interviews,

which is part of the qualitative research methodology.

Therefore the combination of these methods offers a greater complimentary

effect in the study findings (Rees & Bath, 2001). It has been further argued that

although most researchers develop expertise in one style, the two methods or

styles have significantly different complimentary strengths (Neuman, 2000).

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62

Methodology Health Promotion Needs of Stroke Patients

CHAPTER THREE

METHODOLOGY 3.1 Introduction This chapter explores the method utilized in the study, in which data collection

was done by a self-administered questionnaire survey and face-to-face

interviews. Included in the chapter are descriptions of the research setting, study

sample and study designs. A description of the pilot studies and how the data

analysis was conducted is also explained. Finally, the issues of ethical

consideration regarding the study are reported.

3.2 Research setting The study was conducted in the Western Province, South Africa. This province

is divided into several regions, with each region being divided into several

districts. The setting for the current study was the Metropole Region of the

Western Cape, which was divided into various health districts. These include the

Central Health District, the Eastern Health District, Khayelitsha, Klipfontein,

Mitchells Plain, Northern Panorama, Southern Health District and the Tygerberg

Health District. The 43 Community Health Centres (CHCs) in the Metropole

region of the Western Cape all fall into one of the above mentioned districts. The

map below was obtained from the City of Cape Town Health Facilities and

demarcates the eight different Health Districts accessed in this study.

62

N7

N7

N2N2

R30

4R

304

R31

0R

310

WE

ST C

OA

ST R

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WE

ST C

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ST R

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DAS

SEN

BER

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D

DAS

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R44

R44

PHILADELPHIA ROAD

PHILADELPHIA ROAD

BOTTELARY ROAD

BOTTELARY ROAD

BADEN PO

WELL

DRIVE

BADEN PO

WELL

DRIVE

SPINE ROAD

SPINE ROAD

ME

WW

AY

ME

WW

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OLD MAIN ROAD

OLD MAIN ROAD

FAURE MARINE DRIVE

FAURE MARINE DRIVE

VICTORIA

RO

AD

VICTORIA

RO

AD

VISSERSHOK ROAD

VISSERSHOK ROAD

PLATEAU ROAD

PLATEAU ROAD

MA

IN R

OA

D

MA

IN R

OA

D

SW

AR

TK

LIP

RO

AD

SW

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TK

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OU KAAPSE WEGOU KAAPSE WEG

KLEIN DASSENBERG ROAD

KLEIN DASSENBERG ROAD

BRAKKEFONTEIN

BRAKKEFONTEIN

MELKBOSSTRAND ROAD

MELKBOSSTRAND ROAD

BR

OA

DW

AY

BO

ULE

VA

RD

BR

OA

DW

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SHEFFIELD ROADSHEFFIELD ROAD

DURBANVILLE ROAD

DURBANVILLE ROAD

VAN

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BEE

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VAN

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KOMMETJIE ROAD

KOMMETJIE ROAD

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PL

ES

SIS

DR

IVE

PRIN

CE

GEO

RG

E D

RIV

E

PRIN

CE

GEO

RG

E D

RIV

E

BLACKHILL ROAD

BLACKHILL ROAD

DE WAAL DRIVE

DE WAAL DRIVE

SIR LO

WR'S R

OAD

SIR LO

WR'S R

OAD

BLAAUWBERG ROAD

BLAAUWBERG ROAD

STELLENBOSCH ROAD

STELLENBOSCH ROAD

PLATTEKLOOF ROAD

PLATTEKLOOF ROAD

SETTLERS WAY

SETTLERS WAY

VANGUARD DRIVE

VANGUARD DRIVE

MA

RIN

E D

RIV

E

MA

RIN

E D

RIV

E

BROADW

AY

BROADW

AY

KOEB

ERG

RO

AD

KOEB

ERG

RO

AD

WITSANDS ROAD

WITSANDS ROAD

TABLE BAY BOULEVARD

TABLE BAY BOULEVARD

DU

RB

AN

VIL

LE

AV

EN

UE

DU

RB

AN

VIL

LE

AV

EN

UE

VIKING WAYVIKING WAY

CONSTANTIA MAIN ROAD

CONSTANTIA MAIN ROAD

KU

ILS

RIV

ER

FR

EE

WA

Y

KU

ILS

RIV

ER

FR

EE

WA

Y

LA B

EL

LE R

OA

D

LA B

EL

LE R

OA

D

OM

UR

AM

BA

RO

AD

OM

UR

AM

BA

RO

AD

CA

MP

S B

AY

DR

IVE

CA

MP

S B

AY

DR

IVE

DE WAAL ROADDE WAAL ROAD

MODDERDAM ROADMODDERDAM ROAD

RH

OD

ES

DR

IVE

RH

OD

ES

DR

IVE

OK

AV

AN

GO

RO

AD

OK

AV

AN

GO

RO

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OLD

OA

K R

OA

D

OLD

OA

K R

OA

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JAN S

MUTS D

RIVE

JAN S

MUTS D

RIVE

GIE

L B

AS

SO

N D

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GIE

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AS

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RIV

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ED

INB

UR

GH

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ED

INB

UR

GH

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UNION A

VENUE

UNION A

VENUE

FRANS CONRADIE DRIVE


KR

OM

BO

OM

PA

RK

WA

YK

RO

MB

OO

M P

AR

KW

AY

BL

AC

K R

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R P

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AY

BL

AC

K R

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R P

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AY

SIM

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VA

N D

ER

ST

EL F

RE

EW

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SIM

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VA

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ER

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EL F

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KLOOF N

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KLOOF N

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BUIT

ENG

RAGT

BUIT

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RAGT

SP

INE

RO

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EX

TS

PIN

E R

OA

D E

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CAPE

FLATS

FREEW

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CAPE

FLATS

FREEW

AY

EASTERN BOULEVARD

EASTERN BOULEVARD

HOUT BAY R

OAD

HOUT BAY R

OAD

FRANCIE VAN ZIJL D RIVE

FRANCIE VAN ZIJL D RIVE

MIK

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IEN

AA

R B

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LE

VA

RD

MIK

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IEN

AA

R B

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LE

VA

RD

SABLE STREET

SABLE STREET

DE VILLIER S DRIVE

DE VILLIER S DRIVE

OTTERY ROAD

OTTERY ROAD

MODDERDAM EAST-WESTMODDERDAM EAST-WEST

CONSTANTIA ROADCONSTANTIA ROAD

AIRPOR T APPROACH ROADAIRPOR T APPROACH ROAD

STEENBER G ROADSTEENBER G ROAD

STRAND ROAD

STRAND ROAD

KENDALL ROAD

KENDALL ROAD

MAIN STREET

MAIN STREET

NE

W E

ISLE

BE

N R

OA

DN

EW

EIS

LEB

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RO

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SANDOWN ROAD

SANDOWN ROAD

HINDLE ROADHINDLE ROAD

DU

INE

FO

NT

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RO

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DU

INE

FO

NT

EIN

RO

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N1N1

ST

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KUIL

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MAIN ROAD

MAIN ROAD

R30

4R

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KU

ILS

RIV

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FR

EE

WA

Y

KU

ILS

RIV

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FR

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WA

Y

WELLINGTON ROAD

WELLINGTON ROAD

OLD

MA

IN R

OAD

OLD

MA

IN R

OAD

PLATTEK

LOO

F RO

AD

PLATTEK

LOO

F RO

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KR

OM

BO

OM

PA

RK

WA

YK

RO

MB

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M P

AR

KW

AY

FRANS CO

NRADIE D

RIVE

FRANS CO

NRADIE D

RIVE

VA

NG

UA

RD

DR

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VA

NG

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RD

DR

IVE

WE

LLING

TON

RO

AD

WE

LLING

TON

RO

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ME

WW

AY

ME

WW

AY

MA

IN R

OA

DM

AIN

RO

AD

NORTHERN PANORAMANORTHERN PANORAMA

EASTERNEASTERN

SOUTHERNSOUTHERN

CENTRALCENTRAL

TYGERBERGTYGERBERG

KLIPFONTEINKLIPFONTEIN

KHAYELITSHAKHAYELITSHAMITCHELLS PLAINMITCHELLS PLAIN

11

33

88

1919

66

77

1616

22

1818

2020

44

1515

55

99

1717

1212

1313

1010

1111

1616

1414

Parow

Belhar

Wynberg

Mowbray

Goodwood

Lakeside

Bellville

Noordhoek

Westridge

Gugulethu

Woodstock

Silvertown

Green Point

Saxonsea Clinic

Area 3 Blue Downs

Area 1 Kraafontein

Air Pollution Control

Oostenberg Head OfficeEnviromental and Milk Lab

Scottsdene Satellite Office

Kuilsriver Satellite Office

Community Health Care Centre

Area 2 Brackenfell/Kuilsrivier

Environmental Health Food Control

Centralised Offices Somerset West

Blaauwberg Administration Building

Parow CHC

Delft CHC

Mamre CHC

Site B C HC

Ikwezi CHC

Mfuleni CHC

Retreat CHC

Goodhope CHC

Tafelsig CHC

Langa Clinic

Maitland CHC

Vanguard CHC

Macassar CHC

Kuyasa Clinic

Uitsig Clinic

Kleinvlei CHCGugulethu CHC

Woodstock CHC

Nolungile CHC

Luvuyo C linic

Vuyan i Clinic

Heideveld CHC

Netreg Clinic

Alphen Clinic

Wynberg Clinic

Ocean View CHC

Wesbank Clinic

Dirkie Uys CHC

Crossroads CHC

Kensington CHC

St Vincen t CHC

Scottsdene CHC

Sarepta Clinic

Ruiterwacht CHC

Westlake Clinic

Seawinds Clinic

Parkwood Clinic

Lotus River CHC

Phil lip i Cl inic

Green Point CHC

Phumlani Clinic

Guguletu Clinic

Bothasig Clinic

Grassy Park CHC

Maitland Clinic

Durbanville CHC

Harmonie Clinic

Reed Street CHC

Leonsdale Clinic

Klip Road Clin ic

Hanover Park CHC

Kraaifontein CHC

Hillcrest Clin ic

Factreton Clinic

Lentegeur Clinic

Rocklands Clinic

Westr idge Clinic

Mzamomhle Clinic

Mayenzeke Clinic

Lansdowne Clin ic

Newfields Clin ic

Honeyside Clinic

Manenberg Clinic

Brown's Farm CHC

Bishop Lavis CHC

Elsies River CHC

Northpine Clinic

Claremont Clinic

Fish Hoek Clinic

Saxon Sea Clinic

Blue Downs Clinic

Masiphumelele CHC

Muizenberg Clinic

Diep River Clinic

Bruce R oad Clinic

Bloekombos Clinic

Table View Clinic

Silvertown Clinic

Ruimte Road Clinic

Lotus River Clin ic

Wallacedene Clinic

Brackenfell Clin ic

Robbie Nurrock CH C

Protea Park Clinic

Empilisweni Clinic

Matthew Goniwe CHC

Dr. Abdurahman CHC

Masincedane Clinic

Lady Michaelis CHC

Groenvallei Cl inic

Site B Youth Clinic

Bellvi lle South CHC

Russels Rest Clinic

Hanover Park ClinicCrossroads 1 Clinic

Elsies River Clinic

Chestnut Way C linic

Spencer Road Clinic

Fagan Street Clinic

Gordon's Bay Clinic

Valhalla Park Clin ic

Chapel Street Clinic

Strandfontein Clinic

Hout Bay Harbour CHC

Somerset West Clinic

Matroosfontein Clinic

Rustof (Gustrouw) CHC

Michael Mapongwana CHC

Strand Boland Bank CHC Sir Lowrys Pass Clinic

Pella Satell ite Clinic

Brighton Street Clinic

Unathi Satel lite Clinic

Adriaanse Street Clinic

Red Hill Satellite Clinic

Hazendal Satell ite Clin ic

Mandalay Satel lite Clinic

Hout Bay Main Road Clinic

Weletevreden Valley Clinic

Pinelands Satell ite Clinic

Sun Valley Satelli te Clinic

Simons Town Satelli te Clinic

Fisantekraal Satell ite Clinic

Pelican Park Satell ite Clin icGrassy Park Civic Centre Clinic

Schotscheskloo f Satel lite Clinic

Melkbos Clinic and Mob ile Services

Eastridge Clinic and Mitchels Plain CHC

Eers te RiverEers te River

Hampton HouseHampton House

Louis LeipoldtLouis Leipoldt

Strand HospitalStrand Hospital

Parow MedicrossParow Medicross

Tokai Medi-CrossTokai Medi-Cross

N1 C ity HospitalN1 C ity Hospital

Kingsbury ClinicKingsbury Clinic

Wesf leur HospitalWesf leur Hospital

Libertas HospitalLibertas Hospital

Kenilworth ClinicKenilworth Clinic

Crescent HospitalCrescent Hospital

Cape Eye H ospitalCape Eye H ospital

Monte Vis ta ClinicMonte Vis ta Clinic

Claremont HospitalClaremont Hospital

Brackenfell ClinicBrackenfell Clinic

Langerberg MedicrossLangerberg Medicross

Durbanville HospitalDurbanville Hospital

Milnerton Medi-clinicMilnerton Medi-clinic

Jan S Marais HospitalJan S Marais Hospital

Vergelegen Medi-ClinicVergelegen Medi-Clinic

Stepping Stones CentreStepping Stones Centre

Vincent Pallot ti HospitalVincent Pallot ti Hospital

New Lands Surgical ClinicNew Lands Surgical Clinic

Gatesville Medical CentreGatesville Medical Centre

Aevitas/Tygerberg HospitalAevitas/Tygerberg Hospital

Constantiaberg Medi-ClinicConstantiaberg Medi-Clinic

Broad Road Surgical ClinicBroad Road Surgical Clinic

SouthernCross/Wynberg HospitalSouthernCross/Wynberg Hospital

Mitchells Plain Medical CentreMitchells Plain Medical Centre

RED CR OSS

WOODSTOCK

VALKENBERG1 VALKENBERG 2

GROOTE SCHUUR

WESFLEUR HOSPITAL

STIK LAND HOSPITAL

VICTORIA HOSPITAL

SOMERSET HOSPITAL

HOTTENTOT HOSPITAL

FALSE BAY HOSPITAL

LENTEGEUR HOSPITAL

TYGERBERG HOSPITAL

GF JOOSTE HOSPITAL

EERSTE RIVER HOSPITAL

MOWBRAY MATERN ITY HOSPITAL

ALEXANDRA CARE & REH ABILIATION

Nyanga CHC

Ravensmead CHC

Zakhele Clinic

Civic Cen tre Clinic

Albow Gardens Clinic

Lavender Hil l Cl inic

Carinus Street Clinic

Note:

CITY OF CAPE TOWNISIXEKO SASEKAPA

STAD KAAPSTAD

0 2,500 5,000 7,5001,250Meters

1:90,000

CITY OF CAPE TOWNHEALTH FACILITIES

Ref: 200

TABLE BAY

FALSE BAY

Health Districts

Legend

Environmental Health Offices

Government Hospitals

Private Hospitals

Clinics

Subcouncils

Major Roads

Railways

Primary Arterials

CENTRAL

EASTERN

KHAYELITSHA

KLIPFONTEIN

MITCHELLS PLAIN

NORTHERN PANORAMA

SOUTHERN

TYGERBERG


The table below indicates the distribution of disability in the various Health

Districts as released by the Integrated Provincial Disability Strategy in 2004. No

data was available for the Khayelitsha, Klipfontein and North Panorama districts.

It is also not known to what extent stroke make up the figures.

Table 3.1: Distribution of disability in the various Health Districts

Health District Total Disabled Population %

________________________________________________________________________

Central 31355 33.4%

Eastern 3662 3.8%

Mitchells Plain 41467 44.2%

Southern 4456 4.8%

Tygerberg 13058 13.8%

________________________________________________________________________

Total 93998 100

There are a number of community health centres in each of the health districts.

Community health centres are primary health care centres which provide

comprehensive services encompassing preventative, promotive, rehabilitative

and curative care. Preventative care includes immunization programmes whilst

promotive care encompasses aspects of health promotion and health education,

which aims to have a positive effect on the patient’s recovery process and quality

64


of life. Rehabilitative care, which is the responsibility of the physiotherapist,

occupational and speech therapist, is aimed at improving the patient’s functional

status and quality of life. Rehabilitation may include individual treatments, stroke

group sessions and/or home visits made by the health care professional.

Curative care is mainly provided by medical officers and primary health care

nurses.

Community Health Centres are primary level referral centres for patients treated

at secondary and tertiary institutions. The majority of stroke patients in the

Western Cape would therefore attend Community Health Centres for

rehabilitation, follow-up medical check ups and to receive medication.

3.3 Study design

Both descriptive qualitative and quantitative designs were used to collect data.

Nolan and Behi (1995) indicated that this between-methods triangulation will

result in the study findings being more informative and comprehensive.

The use of both methods provided a valid reflection of the participant’s health-

related behaviours and their own experiences with stroke rather than using either

quantitative or qualitative methods alone.

The purpose of quantitative research is to describe, explain or predict

phenomena (Domholdt, 1993). In the current study the phenomena refers to the

health promotion needs of stroke patient’s accessing Community Health Centres

in the Metropole region of the Western Cape. Quantitative research designs are

65


structured and can be classified as non-experimental, quasi-experimental and

experimental (Domholdt, 1993). The current study was non-experimental, as it

did not involve the manipulation of an independent variable. A cross sectional

survey was the design used for the quantitative aspect of the study. Surveys

have been defined as ‘systems for collecting information to describe, compare,

and predict attitudes, opinions, values, knowledge and behaviour (Domholdt,

2000).

The survey constitutes a descriptive design in which the approach is a non-

experimental one and aims to describe specific phenomena or variables or to find

relationships between variables. The survey approach provides data about the

present as it can tell what people are thinking, doing, anticipating, and planning

at this time. It provides the researcher with an opportunity to use his creativity,

since he is the one who determines the area to be surveyed and the method by

which he will use to extract all the facts. Another advantage of the survey

approach is that it has a high degree of representativeness in proportion to the

sample size (Treece & Treece, 1982). Phillips (1966) believes that the survey

approach is valuable because the survey can provide data about an individual’s

expectations, values, and relationships necessary to understand his behaviour.

Qualitative research is grounded in a concern with peoples everyday realities,

seeking to understand how people experience and make sense of their lives

following a devastating event such as a stroke (Hammell, Carpenter & Dyck,

2000). A phenomenological approach was used as the qualitative study design

66


in the study. The purpose of the phenomenological approach is to ‘give voice’ to

the person being studied, and requires that the researcher present the subject’s

view of his or her world (Holstein & Gubrium, 1994). This allowed the qualitative

data to complement the quantitative data, and to provide a deeper understanding

of the findings of the study, as well as to illustrate and highlight the participants’

views of their health promotion needs.

This will provide a reflection of the participants’ health-related behaviours and

their own experiences of living with a stroke, rather than using either qualitative

or quantitative methods alone.

3.4 Research Subjects

3.4.1 Sample for quantitative data collection

Stroke patients receiving services from Community Health Centres in the

Metropole region of the Western Cape formed the sample for the quantitative

part of the study. A convenient sample of four hundred and eighteen (418)

stroke patients, representing each of the health districts of the Metropole region

of the Western Cape, participated in the quantitative part of the study. Samples

of convenience involve the use of readily available subjects (hence the unequal

number of stroke patients from the various districts) and are a common form of

sampling used in Physiotherapy Research (Domholdt, 2000). A total of 74

patients were recruited from the Central Health District, 62 from the Eastern

Health District, 4 from the Northern Panorama District, 10 from the Southern

67


Health District, 34 from Khayelitsha, 63 from Mitchells Plain, 4 from Klipfontein

and 166 from the Tygerberg Health District. All of the participants accessed their

nearest community health centre either for medication, rehabilitation services or

follow-up medical care.

3.4.2 Sample for qualitative data collection A purposive sample of 12 stroke patients was selected from the quantitative

sample, and formed part of the study sample for the qualitative section.

According to De Vos (2002), purposive sampling is based on the judgment of the

researcher, in that a sample is composed of elements that contain the most

characteristic, representative or typical attributes of the population.

Characteristics that were considered for purposive sampling included the patients

chronicity of the stroke, as well as the current age of the patient. A total of six

patients in the acute stage (three months or less) post stroke and six in the

chronic stage (more than three months) were selected by the researcher. Three

patients’ in the acute stage, fell into an older age group category (sixty five years

and older) and the other three in a younger age group (less than sixty five years

of age). Of the six patients in the chronic stage, three fell into an older age group

category, and three in a younger age group category.

68


3.5 Exclusion Criteria Patients were excluded from the study if they had severe cognitive and

communicative deficits as a result of a stroke.

3.6 Methods of Data Collection

3.6.1 Quantitative Data Collection A self-administered questionnaire designed by the researcher based on the

literature was used to collect the quantitative data (Appendix D). The

questionnaire consisted of both closed as well as open-ended questions. Closed

format questions restrict the range of possible responses whereas open-ended

questions permit a flexible response that allow for a greater breadth of response

(Domholdt, 2000).

3.6.1.1 Instrumentation

3.6.1.2 Development of the questionnaire The researcher’s first step in developing the questionnaire was to draft items for

consideration for inclusion in the questionnaire. Before writing any items, the

researcher reexamined the purposes of the current study and outlined the major

sections the questionnaire needed to include to answer the questions under

study.

69


The questionnaire is comprised of the following seven sections.

Section A included questions relating to the socio-demographic status of the

patient. Age, gender, martial status, educational qualification, employment status

at the time of the stroke and currently as well as the patients’ access to transport

and residential particulars were determined. These items were developed from

measurements by Stuifbergen (1995), who indicated that contextual factors

included demographic characteristics such as age, gender, marital status and

employment status. These demographic characteristics were found to be

significantly related to positive adjustment and improving self-concept. For

example, question one dealt with the participants’ age. According to numerous

studies, age is inversely related to scores on measures of adjustment, physical

and social health, and quality of life (Brooks & Matson, 1982; Harper et al., 1986;

Stuifbergen, 1995). Section A of the questionnaire addressed the second

objective of the current study. The second objective aimed to identify factors that

influenced the health-related behaviours of stroke patients. Literature suggests

that environmental factors (employment status, accessibility to transport and area

in which the individual lives) have an influence on individuals’ health-related

behaviours.

Section B included information relating to stroke such as how long ago did they

suffer the stroke, what side of the body is affected, were they admitted to hospital

post stroke and the rehabilitative services the participants received. Disability

70


related characteristics along with the socio-demographic factors covered in

section A of the questionnaire, also form part of the contextual factors according

to Stuifbergen’s model. Disease/disability related characteristics are believed to

have a potential influence on the health promoting behaviours and the quality of

life of disabled individuals (Stuifbergen & Rogers, 1997). This section of the

questionnaire therefore addressed the second objective of the study, which

aimed to identify factors that influenced the health-related behaviours of stroke

patients.

Section C included questions about the general health/lifestyle of the stroke

patients. This section addressed the first objective of the study, and aimed to

assess the current health-related behaviours of stroke patients’, accessing

community health centres in the Metropole region of the Western Cape.

Section D focused on the participants’ knowledge about stroke. The

questionnaire asked the participants’ whether health care professionals educated

them about what a stroke is, the causes of stroke, how to prevent a further stroke

as well as the prevention of secondary complications. Therefore, shortfalls in the

stroke patient’s knowledge about stroke could be identified and the appropriate

measures taken to amend the lack of stroke related knowledge.

71


Section E dealt with the issue of support. Question 46 investigated what support

(physical and emotional) the stroke patients felt they needed post stroke,

including who they felt should be providing the support.

Section F included questions relating to the physical mobility of stroke patients.

Participants were requested to respond to an item about physical activity, ‘Do

you participate in any kind of physical activity or exercise like walking, gym,

exercising in a stroke group on a regular basis, for half an hour each time?’ This

was included to assess participation in physical activity as a health-related

behaviour. A number of other issues that were identified in the literature were

assessed, such as the patient’s awareness of secondary complications in stroke.

Section G comprised a set of items that identified programmes and activities the

participants perceived as essential to improve their well-being. These items

assessed perceived health-related needs of the participants in the quantitative

part of the study. This section addressed the third objective of the study by

determining the health promotion needs of the study sample.

Even during this first draft of the questionnaire, the researcher took into

consideration the issues of format and comprehensibility. The font in which the

questionnaire was typed was not an atypical font and so potential difficulty in

reading the questionnaire was avoided. A second aspect of the readability was

the reading level required to understand the questionnaire. The researcher tried

to phrase questions in a non-ambiguous way and unnecessary jargon was

72


avoided. Since the format of questions changed from item to item, the

instructions on how to complete each question were made very clear and specific

(e.g., “Tick appropriate option/s”).

3.6.1.3 Peer Review Once the draft was written the questionnaire was subjected to a peer view, by

collegues knowledgeable in the field of health promotion and stroke

management. This peer review was essential to check for content validity

(Domholdt, 2000). The peer review brought to the researcher’s attention the

need to include a separate section on support, and to include the open-ended

question to allow participants to express any views they had on the issue of

support and what support they feel they need since having a stroke.

It was suggested that a question relating to whether participants have access to

transport, be added to the original questionnaire. If participants indicated that

they did have access to transport, they had to indicate whether it was private

transport or public transport. If participants did not have access to transport they

had to indicate how they then get from point A to point B. Suggested options

provided for this question were, walking, using a wheel-chair and forced to stay

at home because of lack of transport.

Another suggestion was that Conradie Care Centre be added in as an extra

option in question 21, as it is one on the main rehabilitation centres in the

Western Cape and numerous stroke patients are admitted here.

73


3.6.1.4 Pilot Study A pilot study was carried out to pre-test the questionnaire, thus determining the

content validity of the instrument for possible changes before it was

administered. The questionnaire was therefore pre-tested on eight individuals

who attend a weekly stroke group held in Retreat, Western Cape. These eight

individuals would not participate in the study. A number of changes were made

following the responses given by the participants.

A few amendments were made to the socio-demographic data section. Under

the question relating to the participants maritial status, divorced was added as an

extra option. In the original questionnaire the question ‘were you employed at

the time of your stroke?’ was included. If participants answered yes to this

question a follow-up question regarding the specific type of work they were

involved in was included. If they answered no to the original question

participants were given options to choose from as the reasons why they were not

employed. The pilot study brought to the attention of the researcher that the

current employment status of stroke patients is an important aspect of the socio-

demographic data that had been overlooked. Therefore the question ‘are you

currently employed?’ was added to the questionnaire. If participants answered

yes to this question, they were asked in the form of an open-ended question what

type of work they are involved in. If participants answered no, they had to mark

the corresponding reason for this from a list of options provided by the

researcher. Section B of the questionnaire-Information relating to stroke had

74


only two minor amendments. The pilot study brought to the researcher’s

attention that some stroke patient’s left and right sides of the body were affected

by stroke. Therefore an extra option ‘both sides’ had to be included in question

17 Stroke patients had to indicate whether they were admitted to a centre for

rehabilitation. If they answered yes, then they had to mark which of the centres

they received rehabilitation services at. An additional option ‘other, please

specify’ was given to the participants as in the pilot study it was noted that some

patients were admitted to rehabilitation centres in other provinces, and have

since relocated to the Western Cape. Patients involved in the pilot study had

difficulty understanding what the researcher meant by the term’ rehabilitation

services’. Therefore for greater understanding of the participants, the question

‘have you ever received any rehabilitation services?’, was changed to ‘have you

ever received rehabilitation services such as physiotherapy, occupational

therapy, speech therapy?’.

Three amendments were made to Section C- general health/lifestyle to add more

clarity to the following questions. The question ‘did you drink at the time of your

stroke?’ was clarified by rephrasing it to read ‘did you drink alcohol at the time of

your stroke?’ Three of the original options participants had to choose from for

the question ‘how much alcohol do you drink at one time on average?’ were

deleted from the questionnaire. These options were, ‘one bottle of wine, more

than one bottle of wine’. Instead the options ‘one glass of wine, two glasses of

wine and more than two glasses of wine’ were included. Another change was to

75


the question ‘have you changed your eating habits/diet since having the stroke?’

Originally the options provided for this question were, ‘yes, no: too expensive and

no: did not know about changing my diet’. Instead of the above mentioned

options, participants were now to mark either yes or no. If participants answered

no, they had to either indicate the reason by marking options provided by the

researcher, or write their reasons down in the space provided. Participants were

also given a yes, no option for the question ‘Do you take your medication as

prescribed?’ If participants answered no, they had to indicate the reasons why by

either marking the most appropriate option provided by the researcher or by

writing their reasons down in the space provided.

Participants had difficulty in understanding the first question in section E: support.

Participants did not know what the researcher was referring to with the word

support. To amend this problem the question ‘what support do you feel you need

since having a stroke?’ was changed to ‘what support (physical and emotional)

do you feel you need since having a stroke?’

No amendments were made to section F: physical mobility and section G:

perceived health-related needs.

3.6.1.5 Translation, Reliability and Validity of the Questionnaire A professional translator translated the questionnaire from English into both

Afrikaans and Xhosa, since English will not be the majority of participants’ first

76


language. In order to ensure that the translated questionnaires assess what the

original English version intended to assess, another translator translated the

questionnaires from Afrikaans and Xhosa, back to English. This version was the

same as the original questionnaire set in English. Therefore, translating the

questionnaire in the Afrikaans and Xhosa languages back to English eliminated

the possible loss of false validity.

Reliability and validity are fundamental concerns in all measurements. Reliability

refers to dependability or consistency of the measurements (Carr, 1995; Redfern

& Norman, 1994). By using both quantitative and qualitative methods

simultaneously, the results were more reliable than if one method was used

alone. Although the two methods operate from entirely different scopes, related

areas have been identified (Neuman, 2000). Integrating the two methods,

called triangulation of method reduces the possibility of bias and produces results

that are more reliable with complimentary strengths (Rees & Bath, 2001).

As part of the present study a test-retest reliability study was conducted using a

sample of 10 stroke patients from the English language version of the

questionnaire, to test for any variations in the responses. Chronbach’s alpha for

the test-retest was between 0.95 and 1.00 for the different sections of the

questionnaire.

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3.6.1.6 Procedure The researcher as well as trained research assistants administered the

questionnaire to the participants on a one to one basis, ensuring correct

completeness of the questionnaire. The research assistants were nursing sisters

and community based carers working for various non-governmental

organizations in the various districts of the Metropole region of the Western

Cape. A group of fourth year physiotherapy students from the University of the

Western Cape who were posted at various community health centres, also

assisted with the collection of the quantitative data. Each of the research

assistants were individually trained by the researcher to ensure accurate

completion of the questionnaire. Before each research assistant could begin the

collection of quantitative data for the study, two ‘practice’ questionnaires had to

be completed on stroke patients of their choice. The researcher then checked to

ensure that the questionnaires were completed correctly and the research

assistants could discuss any problems they experienced relating to the

completion of the questionnaires. Comprehensively training all of the research

assistants (who came from different backgrounds) ensured uniformity and

accuracy when collecting the quantitative data.

Stroke patients who never attended formal rehabilitation at the community health

centres, but who still accessed these centres for medical check-ups or to collect

medication were also included in the study. This made the sample a more

representative one. Completing the majority of questionnaires in the comfort of

the participants’ homes, made them feel more at ease and allowed more time to

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be spent with each participant, thereby gaining maximum input from each

individual. Numerous questionnaires were also completed at the various stroke

groups held at the community health centres. All questionnaires in these cases

were completed by the participants either before or after the stroke group so as

not to interfere with the participants exercise regime.

No patients were duplicated in the study as the students and community based

health workers collected data from different settings. The students concentrated

on the various stroke groups and could keep record on which patients they had

or had not seen by the attendance record of each stroke group session. The

community based health workers were each given a different list of possible

patients they could access in a specific area.

3.6.2 Qualitative Data Collection

Face-to-face interviews were used in the current study to provide in-depth

descriptions of the informants’ health-related behaviours, and the reasons for

their engagement in certain lifestyles. The value of face-to-face interviews is

that the researcher can achieve a greater depth of response, maintain control

over who actually responds, determine the opinions of those who cannot read or

write, and have higher response rates (Domholdt, 2000).

The guided interviews (Appendix I), developed from literature (Stuifbergen, 1995)

were purposeful conversations during which the participants’ lifestyle

experiences were explored. The interviews started with a ‘grand tour’ question to

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set the tone of the interview, and to let the participants determine what was

important for them to tell about living with a long-standing disability (Stuifbergen

& Rogers, 1997).

Consequently, the ‘grand tour’ question for this study was ‘Tell me what it is like

for you to live with a stroke, how does stroke affect your life? The remainder of

the interview guide consisted of a series of guided probes that endeavoured to

obtain an in-depth justification of the practice of various health-related

behaviours. The interviews were guided; purposeful conversations during which

the participants’ lifestyle experiences, and the meaning attached to those

experiences were explored in detail.

Patients who were interviewed for the qualitative part of the study were

purposively selected as indicated in section 3.4.2. The researcher contacted the

12 purposively selected patients who met the inclusion criteria to obtain their

consent and willingness to participate in the study. All data was collected by the

researcher. A convenient time and location was determined for the patient

interviews, and the interviews lasted on average fifty minutes.

3.6.3 Trustworthiness of the qualitative data Tendencies from the transcribed interviews were kept as close as possible to the

respondents’ own mode of talking (Thick low inference data) (Shepard, 1997).

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The participating patients were interviewed in the language of their choice and

the researcher arranged a translator when it was necessary. Member checking

was the form of verification used. In this process, informants reviewed the

interpretive ‘story’ that the researcher had generated and were given the

opportunity to correct technical errors or take issue with ways in which the

researcher has interpreted their situation. The researcher then uses this

information to revise the story, or at least to indicate points of departure between

his views and the views of the informants (Domholt, 2000).

3.7 Data Analysis

3.7.1 Quantitative analysis Descriptive statistic analysis using Microsoft Excel ® was employed to obtain a

profile of the study population. Means, standard deviations and percentages

were calculated for descriptive purposes and the chi-square test was used to test

for associations between various variables. Various relationships between the

socio-demographic characteristics (age, gender, education, employment status

and disability-related characteristics) were illustrated using frequency tables. A

number of health-related behaviours and factors that influence these behaviours

were analysed using chi-square tests, where the association between these

various variables was determined.

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3.7.2 Qualitative analysis Analysis of the qualitative data began with the transcription of the audiotapes.

All audiotape recordings were transcribed precisely word for word. The

transcriptions were compared to audiotape recordings and field process notes

several times to verify accuracy (Neumann, 2000). After reading the

transcriptions of all the interviews and process notes a number of times, analysis

of all interview data began with content analysis.

Analysis was a procedure that started with discovering strong themes running

through the data (Stuifbergen & Rogers, 1997). In this way, data was coded in

broad categories according to the research questions. For example, ‘What were

the health-related behaviours the participants were engaged in?’ Alternatively,

‘What factors influenced the participants’ involvement in certain health-related

behaviours?’ In the second stage, any data that depicted the smallest

information units was identified (Rees & Bath, 2001). An information unit is any

smallest amount of information that is informative by itself (Rees & Bath, 2001).

In the final stage of the analysis, information units were categorized into themes

related to health-related behaviours, reasons for engaging in various behaviours

and factors that influence involvement in certain behaviours. After establishing

the themes, corresponding verbatim quotations were used to support all themes.

In order to maintain anonymity, participants’ names were changed and cited

using the code P1 to P12 for all the participants.

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In order to gain a deeper understanding of the results, quantitative data was

compared and supplemented by qualitative analysis and vice versa to qualify the

process of between-methods triangulation (Neuman, 2000; Nolan & Behi, 1995;

Redfern & Norman, 1994; Rees & Bath, 2001).

To achieve triangulation for confirmation, convergent, inconsistent and

contradictory results between textual qualitative data and numerical data were

determined. In order to achieve triangulation for completeness, numerical data

that expanded on interview findings were highlighted (Rees & Bath, 2001).

3.8 Ethical Considerations

Approval for the implementation of the study was obtained from the Senate

Higher Degrees Committee of the University of the Western Cape. Permission to

conduct the study was also obtained from the Medical Superintendent of the

Community Health Services Organisation (Appendix B). Informed consent was

obtained from all patients participating in this study (Appendix C, E and G). It

was explained in the consent form that the participants were ensured

confidentiality and anonymity and the right to withdraw from the study at any

stage. Patients were ensured that involvement in this study will not influence their

future rehabilitation in any way. For the qualitative part of the study, every

individual participant who agreed to participate in the study, signed a consent

form before participating in a 45 to 60 minutes audiotape interview. The

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researcher ensured the availability of support counseling at the Community

Health Centres should the patients need it. The results of the study will be made

available to all participants, rehabilitation staff and superintendents of the

institutions.

84

Results Health promotion needs of stroke patients

CHAPTER FOUR

RESULTS

4.1 Introduction

In this chapter, the quantitative results of the socio-demographic characteristics

of the study population are described. These comprise age, gender, education,

employment status and disability-related characteristics. A number of health-

related behaviours and factors that influence these behaviours are also

described. Various relationships between health-related behaviours and

demographic characteristics are explained. Additionally, accounts from the in

depth interviews are presented. In giving the accounts of the interviews, the

exact language and phrases used by the participants were preserved. However,

for more clarity in the flow of ideas, the order of the contents was sometimes

slightly altered. For purposes of anonymity and confidentiality, the transcribed

quotations of data from the interviews are cited in the cryptogram P1 to P12.

4.2 Response Rate A total of 420 participants completed the questionnaire for the quantitative part of

the study. A total of three questionnaires were omitted from the study, as certain

sections of the questionnaire were not completed. Four-hundred and seventeen

questionnaires were therefore completed correctly and were eligible for data

analysis. This yielded a response rate of 99.2%

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4.3 Socio-Demographic Characteristics of the Participants

4.3.1 Gender, Age Table 4.1 illustrates the socio-demographic characteristics of the study sample.

Table 4.1: Age versus Gender ________________________________________________________________________Age Male Female n (%) n (%)

30 -54 24 (14.2%) 21 (8.5%)

55 -62 106 (62.3%) 148 (60%)

63 -73 30 (17.6%) 63 (25.5%)

74 -98 10 (5.9%) 15 (6%)

Total 170 247

The mean age of the participants was 61.4 years, with ages ranging from thirty

one to ninety eight years of age. The standard deviation was calculated to be

10.1. Two hundred and forty seven (59.2%) participants were females and one

hundred and seventy (40.8%) were males.

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4.3.2 Gender versus Locality Figure 4.1 illustrates the district where the participants resided according to

gender.

Figure 4.1: Gender distribution according to district

37

18 16 1510

2 1 1

43

10

2015

6 41 1

0

10

20

30

40

50

1 2 3 4 5 6 7 8

Num

ber o

f par

ticip

ants

Female Male

KEY:

1. Tygerberg 5. Khayelitsha

2. Mitchells Plain 6. Southern health district

3. Central health district 7. Northern Panorama

4. Eastern health district 8. Klipfontein

The majority of participants were recruited from the Tygerberg health district

(39%), followed by the Central health district (17.3%). The least amount of

87


participants were recruited from the Klipfontein and Northern Panorama health

districts (2%) respectively.

4.3.3 Marital Status

Table 4.2 illustrates the marital status of the participants according to gender.

Table 4.2: Marital status versus gender

_______________________________________________________________________

Marital Status Female Male

n (%) n (%)

________________________________________________________________________

Married 91 (36.8%) 90 (53%)

Widowed 98 (39.8%) 35 (20.6%)

Divorced/separated 23 (9.4%) 24 (14.1%)

Single 35 (14%) 21 (12.3%)

Total 247 170

________________________________________________________________________

The majority of the participants (43.4%) were married. There were a much larger

number of females who were widowed.

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4.3.4 Employment Status, Educational Level and Access to

Transport

Table 4.3: Socio-demographic characteristics of the study sample

________________________________________________________________________

Variable measured Characteristics Number Percentage

________________________________________________________________________

Education ≤ 6 years 170 40.8%

≥ 7 years 247 59.2%

Employment status Employed 8 1.9%

Retired receiving pension 106 25.4%

No disability grant 142 34.1%

Receiving disability grant 129 30.9%

Unemployed 12 2.9%

No benefits 20 4.8%

Living Conditions Own house 215 51.5%

With family 119 28.5%

Rented house 75 18%

Old age home 8 2%

Access to transport Yes 271 65%

No 146 35%

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With regard to the participants’ educational level, the majority (59.2%) had ≥ 7

years of education, whilst 40.8% had ≤ 6 years of education.

Only eight individuals of the 417 (2%) in the sample of stroke patients were

employed. Six of the eight currently employed individuals fell into the 30-54 age

group, whilst two were between 55 and 62 years of age. Although the majority of

participants (409, 98%) were unemployed, only 31.5% were receiving a disability

grant.

One hundred and six (25.4%) participants were retired receiving a government

pension whilst a further 4.8% were receiving no benefits (neither a disability grant

nor pension). Two point nine percent of participants were currently unemployed

but indicated that their disability would not prevent them from trying to find

employment in the future.

The majority of participants (51.5%) lived in their own house, whilst 28.5% stayed

with family members. Eighteen percent of participants were currently renting

either a house or flat, whilst the minority (2%) resided in an old age home.

A total of 271 (65%) participants had access to either public or private transport.

Of these participants’ who had ‘access to transport’, 64.6% were females (175

out of 271), whilst only 35.4% were males.

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4.3.5 Associated medical conditions/illnesses Figure 4.2 illustrates the various illnesses participants are suffering from in

relation to gender.

Figure 4.2: Illnesses in relation to gender

98

46

213

135

452516 812 10

0

50

100

150

200

250

Female Male

Num

ber o

f par

ticip

ants

Diabetes Hypertension Cardiac problems Obesity Other

The majority of participants (144, 34.5%) suffered from diabetes. Significantly

more females (41%) suffered from diabetes compared to the males (36.5%).

Three hundred and forty eight (83.5%) participants were hypertensive in the

current study. There was no difference between female (89.1%) and male

(87.1%) participants’, when it came to hypertension.

Seventy (21.6%) participants were suffering from cardiac problems. The rates of

cardiac problems for females and males were 23.2% and 19.2% respectively.

The general rate of obesity in the current study was low (N=24, 6.1%), with no

significant difference between the two genders.

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Twenty two (5.3%) participants reported that they suffered from other conditions

besides those featured in the questionnaire. These illnesses included, epilepsy,

blindness, arthritis, tuberculosis and HIV/AIDS.

4.4 Information relating to stroke

Table 4.4: Tertiary and secondary institutions where participants were

admitted.

________________________________________________________________________

Type of institution Frequency Percentage

________________________________________________________________________

Tertiary 135 38.3%

Secondary 159 45.2%

________________________________________________________________________

The majority of participants (71%) suffered their stroke more than 12 months

ago, whilst 19.1% had their stroke 6 or less months ago. A total of 215

participants (52.5%) had a right cerebrovascular accident, whilst 192 (46%) had

a left cerebrovascular accident. A total of 10 participants (2.5%) had suffered

both a right and left cerebrovascular accident.

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Three hundred and fifty two (83.5%) participants reported that they were

admitted to hospital after having the stroke. Of these, 20 (5.3%) were admitted

to a private hospital.

Three hundred and thirty two (94.7%) were admitted into the public sector where

they received tertiary, secondary or primary levels of care as illustrated.

The two tertiary institutions comprised 38.3% of all admissions whilst the

secondary hospitals accounted for 45.2% of all admissions to hospital. Eleven

percent of respondents were not admitted to hospital at the time of their stroke.

A total of 134 participants (32.1%) were referred to a rehabilitation centre.

Table 4.5 represents the frequency distribution of rehabilitation centres where

patients were treated.

Table 4.5: Frequency distribution of admittance to rehabilitation centres

________________________________________________________________________

Centre Name Frequency

________________________________________________________________________

Conradie Care Centre 69

Booth Memorial 31

Western Cape Rehab Centre 23

Panorama 11

Total 134

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The first two rehabilitation centres served 74.6% of the total number of patients

admitted to a centre for rehabilitation post stroke.

The details of participants’ duration of stay at the rehabilitation centres with

relevant frequencies is illustrated in Table 4.6

Table 4.6: Frequency of participants’ duration of stay at the rehabilitation centres

________________________________________________________________________

Duration at Rehabilitation Centre Frequency

________________________________________________________________________

Less than one week 11

One week 8

Between one and two weeks 10

Between two and three weeks 16

Between three and four weeks 25

Longer than four weeks 64

Total 134

________________________________________________________________________

With the exception of the first two rows, the frequencies increased as the

duration of admittance at the rehabilitation centre increased.

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Participants received physiotherapy, occupational therapy as well as speech

therapy at the various rehabilitation centres.

Figure 4.3 illustrates the frequency distribution of the three paramedical sciences:

Physiotherapy, occupational therapy and speech therapy

Figure 4.3: Frequency distribution of the three paramedical sciences

93%

5% 2%

Physiotherapy Occupational therapy Speech therapy

Physiotherapy was used to treat most of the patients (93% overall), but those

who received speech therapy and not occupational therapy had a lower usage of

physiotherapy, namely 78.4%. Similarly, those patients’ who did not receive

speech therapy, but received occupational therapy, also had a lower usage of

physiotherapy, namely 76.9%

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4.5 Health related behaviours The participants’ health-related behaviours assessed included participation in

physical activity, substance usage including smoking and alcohol consumption,

modification of diet and the use of medication.

4.5.1 Participation in physical activity and influencing factors

One hundred and sixty eight (40.3%) participants did not participate in any kind

of physical activity or exercise, while 249 (59.7%) participants participated in

some kind of physical activity or exercise. Among those who participated in

physical activity (N=249), 113 (45.4%) participated on a daily basis, 59 (23.7%)

participated three times a week and once a week respectively, and 18 (7.2%)

participated only a few times per month. A number of issues, such as socio-

demographic factors and barriers, influenced participants’ choice to take part in

physical activity.

4.5.1.1 Physical activity participation in relation to age groups

Figure 4.4 illustrates the participants’ involvement in physical activity in relation to

age groups.

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Figure 4.4: Physical activity in relation to age groups (n=249)

05

101520253035404550

31-54 (n=98) 55-62 (n=66) 63-73 (n=55) 74-88 (n=30)

Age groups

Perc

enta

ge o

f par

ticip

ants

(10%

)

Eveyday 3 times a week Once a week Hardly ever

The highest percentage of participants (80.6%) who hardly ever or never

participated in physical activity was in the age group 74-98 years, while the

lowest percentage of participants (22%) was in the age group 31-54 years.

The majority of participants (N=51, 45.1%) who participated in physical activity

every day were in the age group 31-51 years. The second highest number

(N=28, 24.7%) of participants who participated every day was in the age group

55-62 years, followed by 26 (23%) in the age group 63-73 years. Only 7% of

participants (N=8) from the 74-98 age group participated in physical activity on a

daily basis. The number of participants who participated three times a week was

24 (40.6%) in the age group 31-54 years, 20 (33.8%) in the age group 55-62

years, 10 (16.9%) in the age group 63-73 years and 5 (8.4%) in the age group

74-98 years. An equal number of participants (N=13, 22%) who participated in

97


physical activity once a week were in the age groups 55-62 years and 74-98

years. The highest number of participants who participated in exercise once a

week was 19 (32.2%) in the age group 31-54 years, followed by 14 (23.7%) in

the age group 63-73 years.

4.5.1.2 Physical activity in relation to gender and educational level

Table 4.7 presents the figures of participation in physical activity in relation to

gender and educational level.

Table 4.7: Frequency of physical activity participation in relation to gender and

educational level (n=249)

________________________________________________________________________

Everyday 3 times Once a week Hardly ever a week

________________________________________________________________________

N (%) N (%) N (%) N (%)

Gender

Male 48 (46.1%) 21 (20.2%) 26 (25%) 9 (8.7%)

Female 65 (44.9%) 38 (26.2%) 33 (22.7%) 9 (6.2%)

Education

≤ 6 years 54 (50%) 16 (14.8%) 27 (25%) 11 (10.2%)

≥ 7 years 59 (41.9%) 43 (30.4%) 32 (22.7) 7 (5%)

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The majority of subjects (113, 45.3%) participated in physical activity on a daily

basis. These included 48 (46.1%) males and 65 (44.9%) females. Fifty nine

subjects (21 males and 38 females) participated in physical activity three times a

week, whilst another 59 (26 males and 33 females) participated once a week. A

minority of 18 participants (9 males and 9 females) hardly ever participated in

physical activity.

Fifty percent of subjects (N=54) who had ≤ 6 years of education, and 41.9% of

those with ≥ 7 years of education participated in physical activity on a daily basis.

Of those subjects who participated in physical activity three times a week, 14.8%

had received an education of ≤ 6 years, whilst 30.4% had ≥ 7 years of education.

Similar figures (25% and 22.7%) for ≤ 6 years and ≥ 7 years of education

respectively, represented those subjects who participated in physical activity

once a week. Eleven subjects (10.2%) with ≤ 6 years of education and 7

subjects (5%) with an educational level of ≥ 7 years, hardly ever participated in

physical activity. No significant relation was found between gender and physical

activity (p <0.10) as well as age and physical activity (p <0.10).

4.5.1.3 Physical activity in relation to the length of time that has passed

since the stroke Figure 4.5 illustrates the frequency of participation in physical activity in relation

to the time elapsed from having the stroke.

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Figure 4.5: The frequency of participation in physical activity in relation to the

time elapsed since having the stroke.

41 34 38

910

402314

24

39

6

0

20

40

60

80

100

120

6 or less months Between 7-12months

More than 12months

Everday Three times a week Once a week Hardly ever

One hundred and six participants (42.5%) who had suffered a stroke more than

twelve months ago participated in physical activity. Of these, (38) 33.6%

participated in physical activity on a daily basis, 40 (67.8%) exercised three times

a week, 24 (40.6%) participated in exercise once a week, whilst 6 (33.3%) hardly

ever participated in physical activity. Of the 67 participants who had suffered a

stroke between 7-12 months ago, 34 (30%) exercised every day, 10 (17%)

participated in physical activity three times a week, whilst 14 (23.7%) and 9

(50%) participated in physical activity once a week and hardly ever respectively.

Seventy six participants’ suffered a stroke six or less months ago. Of these, 41

(36.3%) participated in physical activity on a daily basis, 9 (15.2%) exercised

100


three times a week, 23 (35.7%) participated in physical activity once a week and

3 (16.7%) hardly ever exercised.

4.5.1.4 Barriers to participation in physical activity or exercise Table 4.8 shows various barriers to participation in physical activity among those

who hardly ever or never participated in physical activity or exercise.

Table 4.8: Barriers to participation in physical activity or exercise (n=254)

________________________________________________________________________

Barriers to do physical activity or exercise Number %

Cost of transport 37 14.5%

Do not know where to exercise 48 19%

Lack of motivation 51 20%

Have other health concerns 26 10.2%

Lack of energy/ not sure if I can manage 92 36.2%

Other reasons: lack of time, lack of interest 10 4%

For two of the barriers, namely, ‘Do not know where to exercise’ (p<0.10) and

‘lack of motivation’ (p<0.05) the males had a higher proportion of ‘yes’ responses.

None of the other reasons (proportion ‘yes’) were significantly different for the

two genders.

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The greatest barrier to participation in physical activity, reported by 32.2% (N=82)

of the participants was a lack of energy and uncertainty if they would cope with

exercise. From the qualitative findings, there was further emphasis to this factor,

as one of the participants explained,

P1: I can’t manage any type of exercise. I used to go to the stroke group but

would feel very tired after the exercises. Every one else exercising in the

group did not get as tired as I did, so I eventually stopped going to exercise.

The second highest barrier, reported by 20% (N=51) of the participants, was a

lack of motivation to participate in physical activity. From the qualitative

interviews, participants gave more clarification regarding lack of encouragement

to start exercising, as one of them explained,

P 11: I do know a few of the exercises I should be doing everyday to keep my

hand and leg moving, but to be honest I just don’t do them. I don’t see

how those exercises will help me move easier. Perhaps if I was

encouraged more by my wife to do the exercises, I will try harder to do

them.

The influence of this factor was further echoed in the following statement, as one

participant said,

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P7: If someone could show me exercises to do I would make an effort to do

them because I want to get stronger. It’s like if I had someone to guide and

motivate me I wouldn’t feel so helpless and afraid about what the future

holds for me.

Not knowing where to exercise was reported by 48 (19%) participants. This fact

is further illustrated by the following quotation from the qualitative interviews,

P8: As far as I know there are no proper facilities in this community for disabled

people like me to use for exercising. Everything is always focussed on

the fit young boys, the soccer and rugby players…[pauses]…its like the

community and government don’t care about our special needs. I think

exercises like weights and riding a bicycle would benefit me but where can

I do it?

The cost of transport also proved to be a barrier to participating in physical

activity for 14.5% (N=37) of the participants. One participant explained,

P10: I am not financially well off, and so can’t afford to join a gym or anything.

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Transport will also be a problem. I don’t know what exercises I am allowed

to do because of my heart problem, so I will rather be safe than sorry and

do nothing. If I could somehow get to the group where they teach the

special exercises, I would be more confident to try.

Twenty six (10.2%) participants were not involved in any physical activities

because of various health concerns. The influence of this factor was explained

by one participant,

P2: I am scared to do any exercises because what will happen if I have a heart

attack or something. I don’t think that I will manage because I am very

weak since having the stroke and I get tired very quickly. It is just a waste of

time and precious energy because it (exercise) will not fix me.

Other barriers included a lack of time to participate in physical activity as well as

a lack of interest in exercising, as reported by 10 (4%) participants.

One of them explained,

P12: I am still fortunate enough to be working after my stroke. When I come

home I am tired and have to still cook for the family. I just don’t have the

time to exercise everyday.

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One hundred and seventy one (41%) participants are currently receiving

physiotherapy on either an individual basis (N=105, 61.4%) or are attending a

stroke group (N=65, 38%). One participant (0.6%) attended physiotherapy on

both an individual and group basis. Those participants who are currently not

attending a stroke group for exercises, reported various barriers that prevented

them from attending such groups. The greatest barrier to not attending a stroke

group was that 151 (36.2%) participants’ were never educated about the

existence of such groups. One participant explained,

P6: This is the first time I am hearing about stroke groups. No one ever

bothered about telling me about them. They (the medical staff) expect you

to just know everything and don’t offer any extra advice and suggestions.

Do I have to pay to go to the stroke group? Because I am poor cos I have to

live off a small pension.

One hundred and eighteen (28.3%) participants could not attend a stroke group

because there were none in close proximity to where they lived. Ninety nine

(23.7%) participants reported that the high cost of transport was the reason as to

why they did not exercise at a stroke group. These barriers were echoed further

by one participant,

P11: I think I would enjoy doing exercises at a stroke group with people who are

in the same position as me. I just have a big problem in getting to the

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clinic to the group. The taxi’s are very expensive and besides that the

nearest rank is still a good ten minutes walk from my house. I don’t think it

would be safe for me to walk that far.

A minority (N=55, 13.2%) felt that they did not need to attend a stroke group for

exercising and support.

P1: I manage fine on my own. I am sure these groups can be beneficial for

some people but personally, I don’t need any extra help.

4.5.2 Use of alcohol, smoking and influencing factors Table 4.9 illustrates the participants frequency of substance usage.

Table 4.9: Substance usage

________________________________________________________________________

Substance usage Yes No N (%) N (%)

Currently smoke 126 (30.2%) 291 (69.8%)

1-5 cigarettes per day 65 (51.6%)



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________________________________________________________________________

Substance usage Yes No N (%) N (%)

Alcohol use 55 (13.2%) 362 (86.8%)

Everyday 14 (25.5%)

3-4 times a week 24 (43.6%)

Once a week 9 (16.4%)

A few times a month 8 (14.5%)

________________________________________________________________________

One hundred and twenty six (30.2%) participants smoked cigarettes. Out of 126

participants (30.2%) who smoked, the majority (N=65, 51.6%) smoked 1-5

cigarettes everyday, followed by 38 (30.1%) who smoked 6-10 cigarettes per

day. Twenty three participants (18.3%) smoked more than 10 cigarettes

everyday.

Of the 55 (13.2%) participants who currently consume alcohol, the majority

consumed alcohol 3-4 times a week (N=24, 43.6%), followed by 14 (25.5%) who

used alcohol everyday. Nine participants’ (16.4%) consumed alcohol once a

week, whilst 8 (14.5%) participants consumed alcohol a few times per month.

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4.5.2.1 Substance usage in relation to age groups Figure 4.6 illustrates the number of participants in each age group in relation to

substance usage.

Figure 4.6: Substance usage in relation to age groups

20

63

2419

1410

17 14

0

10

20

30

40

50

60

70

31-54 years 55-62 years 63-73 years 74-98 years

Age groups

Num

ber o

f sub

stan

ce u

sers

Currently smoke Alcohol use

The majority of participants who smoked (N=63, 50%) were in the age group 55-

62 years, followed by 24 (19%) participants in the age group 63-73 years.

Twenty (16%) participants in the age group 31-54 smoked, compared to 19

(15%) participants in the age group 74-98 years.

With regard to the consumption of alcohol, the majority (N=17, 31%) were in the

age group 63-73 years, followed by 14 (25.4%) in the both the 31-54 and 74-98

year age groups. The minority of alcohol consumers, (N=10, 18.2%) were in the

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55-62 years age group. Chi-square tests indicated a significant statistical

significance between substance usage including alcohol consumption (p<0.001)

and smoking (p<0.002) in relation to age groups.

4.5.2.2 Frequency of substance usage and age groups

Table 4.10 illustrates the participants’ frequency of substance usage in relation to

age groups.

Table 4.10: Frequency of substance usage in relation to age groups

________________________________________________________________________

Age groups 31-54 55-62 63-73 74-98 Total

N (%) N (%) N (%) N (%) N (%)

Currently smoke 20 (16) 63 (50) 24 (19) 19 (15) 126 (30.2)

1-5 cigarettes/day 7 (12) 25(43.1) 15 (25.9) 11 (19) 58 (46)

6-10 cigarettes/day 9 (17) 32 (60.4) 8 (15.1) 4 (7.5) 53 (42)

More than 10/ day 4 (26.7) 6 (40) 1 (6.6) 4 (26.7) 15 (12)

Alcohol use 14 (25.4) 10 (18.2) 17 (31) 14 (25.4) 55 (13.2)

Everyday 2 (33.3) 1 (16.7) 2 (33.3) 1 (16.7) 6 (11)

3-4 times a week 8 (36.4) 3 (13.6) 7 (31.8) 4 (18.2) 22 (40)

Once a week 3 (15.8) 3 (15.8) 5 (26.3) 8 (42.1) 19 (34.5)

Few times a 1 (12.5) 3 (37.5) 3 (37.5) 1 (12.5) 8 (14.5)

month

109


Of the 58 (46%) participants who smoked 1-5 cigarettes a day, the majority

(43.1%) were in the age group 55-62 years. The smallest number of smokers

(N=19, 15%) were in the age group 74-98 years.

The majority of alcohol consumers (N= 8, 36.4%) used alcohol 3-4 times a week

and were in the age group 31-54 years. Eight participants (42.1%) also used

alcohol once a week and were in the 74-98 year age group. A similar number

(N=7, 31.8%) in the age group 63-73 years also consumed alcohol 3-4 times a

week. The smallest number of alcohol users (N=1, 16.7%) were in the age

groups 55-62 years as well 74-98 years.

4.5.2.3 Substance usage in relation to gender and education Table 4.11 shows figures for substance users in relation to gender and level of

education.

Table 4.11: Substance usage in relation to gender and education

________________________________________________________________________

Gender Education ________________________________________________________________________

Male Female ≤ 6 years ≥ 7 years ________________________________________________________________________

Currently smoke 74 52 38 88

1-5 cigarettes/day 33 32 19 46

6-10 cigarettes/ day 27 11 11 27

More than 10/ day 14 9 8 15

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________________________________________________________________________

Gender Education ________________________________________________________________________

Male Female ≤ 6 years ≥ 7 years ________________________________________________________________________

Alcohol use 37 18 17 38

Everyday 9 6 6 15

3-4 times a week 18 5 4 13

Once a week 7 5 6 6

A few times a month 3 2 1 4

________________________________________________________________________

Seventy-four (44%) males smoked, compared to 52 (21%) females. Thirty seven

males (21.8%) consumed alcohol, compared to 18 (7.3%) females. This

amounts to a considerable difference of current alcohol usage between the

genders.

The majority of participants (N=88, 70%) who had ≥ 7 years education smoked,

whilst 38 (69%) participants who consumed alcohol also came from this higher

educational group. For participants with a higher education, it was found that the

females smoked fewer cigarettes per day than the males, but this difference was

only weakly statistically significant (p< 0.10).

111


From the results it was found that if a female smoked, it was likely that she would

also consume alcohol and vice versa (p< 0.001). This positive association was

also evident for the male part of the sample. This relationship proved to be even

stronger for the males (p< 0.0001) compared to the females.

4.5.2.4 Substance usage in relation to time elapsed since having the stroke

Figure 4.7 presents the number of substance users in relation to the time elapsed

since having the stroke.

Figure 4.7: Substance usage in relation to time elapsed since having the stroke.

27

5247

2016 19

0

10

20

30

40

50

60

6 months or less Between 7-12months

More than 12months

Time elapsed since having the stroke

Num

ber o

f sub

stan

ce u

sers

Smoking Alcohol use

Most participants (N=52, 41.2%) who smoked, suffered their stroke between 7-12

months ago, followed by 47 (37.3%) who had a stroke more than 12 months ago.

112


The majority of participants (N=20, 36.5%) who consumed alcohol, suffered their

stroke 6 or less months ago, followed by 19 (34.5%) who had the stroke more

than 12 months ago.

4.5.2.5 Physically inactive participants and substance users

A number of participants were involved in all health-risk behaviours assessed in

this study.

Figure 4.8 illustrates the number of physically inactive participants’ and

substance users in relation to gender.

113


Figure 4.8: Number of physically inactive participants’ and substance users and

their counterparts

21

34

19

22

66

74

37

10

12

30

6

102

52

18

0 20 40 60 80 100 12

Physically inactive,alcohol consumers and

smokers

Smokers and alcoholconsumers

Physically inactive andsmokers

Physically inactive andalcohol consumers

Physically inactive

Smokers

Alcohol consumers

Number of participants

0

Males Females

114


Most participants who combined at least two health-risk behaviours were 49

physically inactive participants and smokers (19 males and 30 females). The

second highest number were 46 alcohol consumers and smokers (34 males and

12 females), while 31 participants’ were physically inactive, smokers and alcohol

consumers (21 males and 10 females). Twenty eight participants’ were both

physically inactive as well as consumed alcohol (22 males and 6 females).

4.5.3 Factors influencing the change of eating habits/diet following stroke Figure 4.9 illustrates the percentage of participants who changed their diet

according to gender.

Figure 4.9: Percentage of participants who changed their diet according to

gender.

56%

44%

Females Males

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Within the female population (N=135, 56%) changed their diet, whilst 73 (44%)

males changed their eating habits p<0.02 since having the stroke. According to

tables not shown here, educational level did not contribute to the change in diet

for both genders. Overall, 50% of the participants changed their diet since

having the stroke.

4.5.3.1 Barriers to changing eating habits/ diet in relation to gender

Figure 4.10: Barriers to changing eating habits/diet according to gender

22

35.4

60.655.2

24.8 21.9

0102030

40506070

Female Male

Valu

es in

per

cent

(%)

Too expensive Did not know about changing dietDid not know how to change diet

The greatest barrier to changing eating habits/diet post stroke, reported by 119

(58%) of the participants was ‘not knowing that they had to change their diet’.

There was no significant difference between the genders for the above barrier.

Fifty eight (28.3%) participants reported that they had not altered their diet post

stroke because it was ‘too expensive’ to do so. There was a significant

116


difference between the opinion of the females and males on the reason ‘Too

expensive’. It was interesting that 34 (35.4%) male participants thought that

changing the diet was too expensive, compared to 24 (22%) females (p<0.05).

Forty eight (23.4%) participants did not alter their diet post stroke because they

‘did not know how to change their eating habits/diet’. For this reason, there was

no significant difference between females and males.

4.5.4 Compliance to medication use Figure 4.11: Reasons for not taking medication as prescribed according to gender

89.2 90

3 7.8 10.5

0

20

40

60

80

100

Females Males

Valu

es in

per

cent

age

(%)

Forgot toLack of knowledge how to take medicationLack of knowledge how often medication should be taken

Two hundred and thirty two (94%) female participants used medication for

various reasons, compared to 153 (90%) males. Of the female participants who

used medication, 102 (44%) reported that they did not always take their

medication as prescribed. Similarly, 76 (50%) males also did not always take

their medication on a regular basis.

117


The majority of females (N=91, 89.2%) and males (N=68, 89.5%) did not take

their medication as prescribed because they ‘forgot to’. Three females (3%)

reported that the reason they did not take their medication as prescribed, was

because it was never explained to them how they should take their medication’.

Eight (7.8%) females and 8 (10.5%) males reported that it was never explained

to them how often they should take their medication.

4.6 Knowledge about stroke

Figure 4.12: The extent to which various health care professionals educated the

stroke patients

44.4

28.3

13.710.6 8.2 7.4

05

101520253035404550

Information received

Valu

es in

per

cent

(%)

Doctor Physiotherapist Community health workerNurse Occupational therapist Speech therapist

Only 257 (61.6%) participants received information about stroke from health care

professionals. No significant difference between the two genders was observed

(p>0.10).

118


The majority of participants (N=185, 44.4%) who did receive information about

stroke, received it from doctors, followed by physiotherapists (N=118, 28.3%).

Fifty seven participants (13.7%) were educated about stroke from community

health workers, 44 (10.6%) by nursing staff, 34 (8.2%) by occupational therapists

and 31 (7.4%) by speech therapists.

One hundred and ninety (45.6%) participants received information about the

various causes of stroke, whilst 127 (30.5%) were educated about what a stroke

is. A further 124 (29.7%) participants were given information on how to prevent a

further stroke, compared to 40 (9.6%) participants who were educated about the

various complications of stroke. It was also investigated whether the participants’

gender and educational level had a significant influence on the information

received, but it did not have any influence on the information outcome.

119


Figure 4.13: Categories of information received about stroke from health care

Professionals.

30.5

45.6

29.7

9.6

0.0 10.0 20.0 30.0 40.0 50.0

Info

rmat

ion

rece

ived

Value in percentage (%)

What is a stroke Causes of strokePrevention of further stroke Complications of stroke

4.7 Support The majority of participants (78, 83.9%) females with an education ≤ 6 years

expected emotional and physical support from their family and friends, compared

to 103 (75.7%) of the more educated females. Thirty seven males (80.4%) with

an education ≤ 6 years expected emotional and physical support from their family

and friends, compared to 37 (80.4%) of the males with an educational level of ≥ 7

years (p<0.05). Collapsed over gender, the lesser educated group showed a

stronger need for support from their family and friends. From the qualitative

findings, there was further emphasis to this factor, as one of the participants

explained,

120


P4: My life is very difficult now (since having the stroke) and I am reliant on

people for help with every day things like bathing and dressing. I think

that the responsibility lies with my children to support me in whatever ways

they can because I have made many sacrifices for them in the past.

Sixty seven (16.1%) participants received support from their church group, whilst

123 (29.6%) participants received emotional and physical support from medical

staff. Gender and educational level did not have an influence on whether

participants seeked support from the church group or medical staff. From the

qualitative interviews, participants gave more clarification regarding support

received from a church group, as one of them explained,

P5: If it weren’t for the love and support I receive from my church, I don’t know

how I would have managed. Ladies from the church group bring me a

lovely cooked meal two times a week as well as help me with things that I

can no longer do for myself, such as cutting my toe nails. It may seem

small, but its more than my own children are doing for me.

Fourteen (15.1%) females with an education ≤ 6 years expected emotional and

physical support from a stroke group and, compared to 34 ( 25 %) of the more

educated females. Ten males (21.7%) with an education ≤ 6 years expected

emotional and physical support from a stroke group, compared to 38 (34.2%) of

the males with an educational level of ≥ 7 years. Males generally had greater

expectations how they could benefit by support from stroke groups. This

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differential did not prove to be significant within both educational groups (p>0.10).

However, if the educational level was collapsed, this differential became

significant (p<0.05).

The following is a quotation from the qualitative interviews, expressing one of the

participant’s views regarding support from a stroke group.

P 10: It’s great to attend a stroke group on a weekly basis. It makes me feel that

I am not alone, and I have made many new friends. We are able to talk

about problems that we all are facing, and come up with solutions

together. We also motivate each other to exercise regularly. There is a

good competiveness that exists when we exercise together, and so we all

put in effort not to be outdone by anybody else in the group.

4.8 Participants’ perceived health-related needs Figure 4.14 illustrates the perceived health-related needs of the participants’ in

their responses to various health-related programmes and activities.

The majority (N=297, 71.2%) of participants desired to attend a programme

where information how to prevent a further stroke would be the focus. Two

hundred and twenty seven (54.4%) participants wanted to be taught how to

prevent pressure sores and contractures, whilst the same amount of participants

felt it was also important for their family members/caregivers to be educated

about stroke. This need was further explained by one participant,

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P3: If my family were taught more about stroke and understood the condition

better, I am sure they would learn how to be more patient and understanding

of me. If only they could understand what I am going through.

Two hundred and twenty (52.8%) participants also desired to learn more about

what a stroke is and the causes of a stroke, whilst 210 (50.4%) perceived

information on how to manage their blood pressure as being essential. Two

hundred and fifteen (51.6%) participants desired to attain new lifestyle habits to

improve their health. One hundred and eighty one (43.4%) participants

considered information relating to the prevention and management of diabetes as

being essential, whilst 185 (44.4%) believed that health interventions also need

to focus on the development of exercise programmes.

In addition, 173 (41.5%) participants considered issues like staying physically

active in daily activities as being important. One hundred and seventy seven

participants’ expressed their need to receive guidance on how to cope with

depression and lack of motivation, whilst 173 (41.5%) participants wanted advice

on how to manage stress.

Although many participants perceived all programmes as fundamental, 83

(19.9%) participants did not desire to attend teachings on how to stop smoking

and 85 (20.4%) participants did not want to learn how to manage their weight

more effectively. Teaching about HIV/AIDS awareness and prevention also

123


featured as one of the least desired teachings with only 110 (26.4%) participants

interested in learning more about this.

During in-depth interviews, participants clarified and gave more meaning

regarding the desire to get relevant information from health care professionals.

One of the participants said,

P1: I think it is very important that you (health professionals) teach us how to

live healthier lives and tell us what things can be harmful to us. I still

smoke and know now why it is bad for me. I don’t want another stroke and

need help to quit.

Numerous participants also expressed frustration with the government and

believe that it should be implementing support programmes for them. One of the

participants explained,

P4: I think that the government should be doing more for us. The authorities are

not aware of the numerous challenges we have to cope with. It would

help a lot if they could maybe provide us with a special bus that just

serves disabled people in the community. At least then we could attend

physiotherapy and fetch our pills from the centre [community health centre].

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Figure 4.14: Participants’ perceived health-related needs

52.8

71.2

54.4

54.4

42.4

44.4

20.4

41.5

19.9

50.4

51.6

26.4

51.6

26.4

0 10 20 30 40 50 60 70 80

Explanation about what strokeis and the causes of stroke

Information on how to preventa further stroke

Teaching how to preventpressure sores and

contractures

Educating familymembers/caregivers about

stroke

Guidence on how to cope withdepression and lack of

motivation

Teaching about exerciseoptions and programmes

Teaching about weightmanagement tips

Staying physically active indaily activities

Prevention/management ofdiabetes and hypertension

Teaching how to managestress

Teaching how to stopsmoking

Blood pressure management

Learning about new ways toimprove health

HIV/AIDS awareness

% yes responses

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4.9 Summary The majority of the participants in the present study were in the age range 55-62

years. The findings of the study indicated that a large number of participants

practiced risky lifestyle behaviours such as physical inactivity, substance usage,

non-compliance to medication use and non-modification to diet. The majority of

participants identified the need for health-promoting programmes.

126

Discussion Health promotion needs of stroke patients

CHAPTER FIVE

DISCUSSION

5.1 Introduction

This chapter focuses on a comparison of the current study’s findings relating to

the health promotion needs, through the identification of the health-related

behaviours of stroke patients with literature. The impact of the findings on

disability as well as the impact of involvement in health-risk behaviours, are also

discussed. Various aspects of health promotion as well as the relevance of the

study findings to physiotherapists and other rehabilitation professionals is also

explored in further detail. Quotes from qualitative interviews are included to

enrich the discussion.

5.2 General Findings Related to Demographic Factors

The findings of the study corroborate several demographic trends reported

consistently in the literature about stroke. The mean age of the participants in

the current study was 61.4 years. This is in slight contrast to the findings of

studies. For example in the study by Bonita et al. (1997), out of a total population

of 1518 subjects, only 20% were 64 years and younger. In a study conducted by

Rosmand (1986) in South Africa the author also found higher incidence of stroke

rates, among those who were 65 years and older. A recent South African study

conducted in the Limpopo Province also found the highest incidence in people

aged 65 years to 84 years (SASPI, 2004). The results of the present study is

127


however similar to the results found by Rhoda (2002), that recorded a mean age

of 59 years. It must also be noted that approximately 20 % of the sample

consisted of black stroke patients who are known to present at a much younger

age than white and coloured patients (National Guideline on stroke and transient

ischaemic attack management, 2001). This factor could have decreased the

mean age of the study sample.

More females (59.2%) than males (40.8%) participated in the quantitative study

survey. This may be due to a response bias as the sample selected for the study

was a sample of convenience. These results differed to those found by Hoffman

(2000), who reported the female to male ratio to be equal in a group of young

stroke clients. Although these results were found for South Africa, international

studies record a slightly higher incidence in males than in females (Bonita et al.,

1997; Bonita, 1992; Bruno, 2000; Stewart, 1999; Thorsveld, Aspulnd,

Kuulasmaa, Rajakangas & Schroll, 1995). This slightly higher incidence of stroke

in males, may be due to the fact that males generally tend to engage in

behaviours (smoking and alcohol use) which predispose an individual to suffering

a stroke.

A total of 176 stroke patients (45.4%) from the study sample were married. This

was slightly lower than the number of married stroke participants in a similar

study, where 56% were involved in a marital relationship (Rhoda, 2002).

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In the current study, 29.9% of the participants were widowed, a factor which

could be expected as the mean age of the population was 61.4 years. This

number was however considerably less than the 64% of widowed participants

that formed part of Rhoda’s (2002) study on stroke patients in the Bishop Lavis

area. The majority of the study sample were single, either as a result of being

divorced, separated, widowed or because they have never married. According to

Stewart and Eales (2002) being single, whether it be due to divorce or even

death of one partner, has been found to be associated with poor adherence to

risk factor modification in a group of hypertensive patients. The fact that the

majority was single may therefore be problematic when wanting to implement

health promotion programmes.

Only 8 individuals of the sample of 417 were employed. This is very

disconcerting as 109 (26.1%) participants were employed at the time of their

stroke. The return to work rate for the study population was therefore 2.9%.

Teasall, McRae & Finestone (2000) as well as Flick (1999) mentioned

discrepancies about the return to work rate post-stroke recorded in the literature,

as ranging between 17% and 51%.

The reasons for this may be due to the difference in the severity of stroke among

the persons studied and differing definitions used for returning to work (Flick,

1999; Teasall et al., 2000). The majority of studies however, record very low

return to work rates. Young stroke clients experience high levels of anxiety about

whether they will be able to return to work post stroke (Teasall et al., 2000). This

129


anxiety could be as a result of not being able to meet their financial

commitments. Most of the participants in the current study, who could not return

to work, were however either receiving a government pension or a disability

grant.

5.3 Participants’ lifestyle behaviours and influencing factors

After an initial stroke, patients remain at continued high risk for recurrent stroke

as well as for myocardial infarction and cardiac death (Williams, 2001; Williams,

Jiang, Matchar & Samsa, 1999). Nearly a third of stroke patients experience

recurrent stroke within 5 years, despite optimal medical management.

(Antiplatelet Trialists’ Collaboration, 1988). Further, comorbid cardiovascular

conditions are present in 75% of stroke patients, representing the leading cause

of death in stroke survivors. (Roth, 1993; Roth, 1994; Sacco, Wolf, Kanner &

McNamara, 1982; Wade, Skilbeck, Wood & Langton, 1984). Stroke patient’s

need to be made aware of this high risk for recurrent stroke and educated how to

best prevent this from occurring by practicing healthy lifestyle-behaviours.

The findings of the study related to the participants’ lifestyle behaviours are

alarming. There is a great concern regarding the participants’ involvement in

various health-risk behaviours. These behaviours include not participating in

physical activity on a regular basis, smoking, alcohol consumption and non-

compliance to medication use. A large number of participants do not partake in

any form of physical exercise, whilst many participants were either smokers or

130


alcohol consumers. In addition most participants did not have access to relevant

information about stroke in general and how to avoid health-risk behaviours.

5.3.1 Participation in physical activity or exercise

Many participants (41% of the females and 39% of the males) did not participate

in any physical activity or exercise. These figures were significantly less than a

study by Mutimura (2001) on lower limb amputee patients’ in Rwanda. Mutimura

found that 64.7% of his study sample was physically inactive. A similar study

investigating the health promotion needs of spinal cord injured patients in South

Africa, also found that many individuals who were previously involved in sports

reported having resorted to sedentary lifestyles after the injury as they believed

that they had lost the ability to participate in physical activity (Majoki, 2001). Lack

of participation in physical activity is common among people with physical

disabilities. In his model of health promotion for people with disabilities,

Stuifbergen (1998) suggests that low exercise participation rates for women are

frequently ascribed to the family responsibilities and societal norms which

support such behavioural choices. In an assessment of lifestyle health

behaviours among individuals with physical disabilities, Steele et al. (1997)

reported a high level of sedentary lifestyle. More recently, Hogan et al. (2000)

further reported that individuals with disabilities, especially from the younger age

groups, were living a physically inactive lifestyle. Despite documented benefits of

physical activity for people with physical disabilities including those who have had

a stroke (Kosma, Cardinal & McCubbin, 2003; Rimmer et al., 1996) it is clear

131


from a number of studies that, habitual physical activity is a missing component

in the lives of most persons with physical disabilities (Cooper et al., 1999;

Rimmer et al., 1996).

Considering that exercise and activity are of prime importance in the

rehabilitation of individuals with physical disabilities including those with stroke,

physical inactivity that is persistently evident among these individuals is of

concern to rehabilitation professionals. To be able to promote physical activity

among these individuals, it is essential that rehabilitation professionals

understand more fully the factors that enable or discourage these individuals’

participation in physical activity. Participants in this study described a number of

factors that influenced their participation or lack of participation in physical

activity.

A recent study reported that active or fit individuals have a 64% lower risk for

stroke. Even moderate levels of physical activity are associated with protection

against ischaemic and haemorrhagic stroke events (Kiely, Wolf, Cupples, Beiser

& Kannel, 1994; Lee, Folsom & Blair, 2003; Wannamethee & Shaper, 1992). It is

not known whether exercise confers similar protective benefits against recurrent

stroke or improves cardiovascular health outcomes in the post stroke population.

However, despite the dangers of reduced physical activity and associated fitness

to all individuals, there remains encouraging evidence regarding the potential to

reverse health risks of previous sedentary living with exercise training. Even

subtle improvements in fitness and daily activity have been shown to pay large

dividends in stroke patients. For persons who have had a stroke, the Stroke

132


Council of the American Heart Association recommends 30 to 60 minutes of

moderate exercise at least 3 or 4 times per week, which should be medically

supervised (particularly for high-risk patients) and adapted depending on

neurological functioning (Wolf et al., 1999). According to Rimmer (1999), there

appears to be no element of habitual physical activity among individuals with

physical disabilities, and many live a physically inactive lifestyle.

It is of concern that after the completion of conventional physiotherapy, there are

no empiric recommendations and few resources promoting regular exercise

during the chronic stroke period. Patients must then often face the functional and

cardiovascular health consequences of physical inactivity while aging with a

chronic disability (Ivey et al., 2005). The results of the current study reflected the

need to promote programmes encouraging physical activity in the stroke

population, accessing community health centres, in the Metropole region of the

Western Cape.

5.3.2 Barriers to participation in physical activity

People with physical disabilities face numerous barriers to participation in

physical activity. These barriers include lack of energy and motivation, lack of

knowledge where and how to exercise, cost of transport, other health concerns,

lack of financial resources and time. In the present study, lack of energy and

being unsure if they could manage any form of physical activity, was one of the

133


major barriers to participation in physical activity or exercise. One participant

further clarified this factor in the qualitative interview as,

P 15: “ When I wake up in the morning it’s like I have none of the energy I

used to have. Just getting dressed is like climbing a mountain for me

and I need a long time to regain my strength. I know I will not

manage well with any exercise, and if I did exercise, it would use up

all the energy I need for more important things like bathing and cooking

for instance”.

Individuals with lower limb amputation also reported lack of energy to be one of

the barriers to physical activity they encounter, but this barrier was less

frequently mentioned with this group than with the current sample of stroke

patients. An explanation for this difference may be due to the fact that the stroke

population is generally much older than the younger amputee group (Mutimura,

2001). Young individuals in general have much higher levels of energy than their

older counter-parts (Mutimura, 2001).

The second highest recorded barrier was lack of motivation, which influenced

participants’ involvement in physical activity. In the qualitative review, one

participant expressed lack of motivation to engage in exercise,

P 6: “I used to be a keen gardener when I was healthy but since having the

134


stroke I don’t feel as motivated as I used to. I think if I had more

encouragement and motivation from my family to become more

active, I would try harder and maybe start gardening again”.

Similarly, another participant said,

P 10: “ No one has ever encouraged me to start with any exercises. I wouldn’t

know what to do anyway.’

This finding is in agreement with the results of numerous other studies. People

with physical disabilities report lack of motivation as one of the main barriers to

participation in physical activity or exercise (Rimmer et al., 2000; Stuifbergen et

al., 1990). Furthermore, women with multiple sclerosis reported interest to

engage in exercise, but lacked the courage to start participation in physical

activity (Stuifbergen & Rogers, 1997).

The third most frequently reported barrier was a lack of knowledge regarding the

location where exercises could be performed. In the quantitative survey, 9.7% of

females and 14.1% of males stated that they did not know where the exercises

should be carried out. One participant further clarified this factor in the qualitative

findings as,

P11: “ I have never heard about any places nearby that cater for the disabled.

135


I can’t go to a normal gym because it will be embarrassing and I don’t

own any of my own gym equipment”.

People with disabilities’ lack of knowledge of where to exercise, is a major barrier

to physical activity participation even in the more developed countries. For

example, lack of knowledge of where to exercise was ranked first by 58% of the

study sample among American women with physical disabilities (Rimmer et al.,

2000). Lack of knowledge of where to exercise has been reported in some other

studies. Mutimura (2001), found that lower limb amputee patients’ in Rwanda

identified lack of knowledge where to exercise as being the number one barrier to

physical activity participation. Similarly individuals with Multiple Sclerosis

identified lack of accessible facilities such as exercise venues and equipment, as

one of the major environmental barriers to participation in physical activity


Additional barriers to participating in physical activity identified in the present

study and have been reported in other studies (Rimmer et al., 2000; Stuifbergen

& Rogers, 1997; Stuifbergen et al., 1990) included, lack of financial resources

having other health concerns and lack of time.

The following excerpt illustrates how a lack of financial resources created a

barrier for participating in physical activity.

P1: “Since having the stroke I no longer can work. That means I have to

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support my family on the disability grant which you know is not a lot of

money. I just can’t afford to pay taxi fares to get to the stroke group”.

Besides that the taxis’ want to charge me double fare, because my

wheelchair takes up an extra space in the taxi”.

The effect of the above mentioned barriers deprived persons with disabilities the

opportunities to increase their overall well-being and quality of life (Stuifbergen et

al., 1990). Lack of financial resources and lack of time appear to be barriers to

participation in exercise that apply to both the disabled and non-disabled

populations (Kalies, 2000; Rimmer, 2000). Most of these barriers to physical

participation have been identified among people with disabilities elsewhere in

developed countries (Messent, Cooke & Long, 1999). To promote regular

physical activity for people with physical disabilities and especially those who

have suffered a stroke before sedentary preferences become habits, barriers

such as the ones mentioned in this study need to be addressed.

5.3.3 Alcohol use, smoking and influencing factors

The number of participants involved in substance usage seemed to vary

according to the type of the substance. The majority of individuals in the current

study were smokers, followed by lower numbers of alcohol consumers, especially

amongst the females. The frequency and quantity of cigarettes smoked daily

was lower than the numbers reported for similar studies. Smoking was also

found to be common among individuals with lower limb amputations (Mutimura,

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2001). Furthermore, higher rates of tobacco smoking were reported among

students with disabilities compared to their non-disabled peers (Hogan et al.,

2000).

Dean et al. (1985) reported that persons with physical disabilities are equally

involved in substance usage regardless of age.

Generally substance usage appeared to be greater in males than females in the

present study. This finding correlated well with the finding by Mutimura, (2001)

where a significant association was found between substance usage and gender.

In this study the males were found to use substances more than the females. A

relatively greater percentage of males than females smoked cigarettes.

Similarly, a relatively higher percentage of males smoked more cigarettes daily

than females. An unexpected result from the current study was that the higher

educated (≥ 7 years education) males smoked more than their lower educated

counter-parts.

Few studies have reported substance usage among people with physical

disabilities, and to the investigator’s knowledge, none have appeared to focus on

gender difference. However Dean et al. (1985) reported higher percentage of

females than males with disabilities to have been substance abusers. This is in

contrast to the results of the current study.

An amazing finding from the qualitative part of the study was that many of the

participants were living off a small government pension or disability grant, yet

were still substance abusers. Since cigarettes and alcohol are expensive, many

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participants even skipped meals or avoided purchasing their monthly medication

so that they could afford to pay for their substance/s of choice. Participants in

the qualitative interviews expressed this.

P10: “I have become very depressed since having the stroke. Now smoking

feels like the only small pleasure I have in life and I wont quit even if it

may eventually kill me.”

P3: “Wine keeps me going from day to day. I have my first glass early when I

wake up. I suppose it makes me happy for the day ahead. I wouldn’t be

coping without it (the wine). It does get expensive even though it’s

cheap box stuff (wine). Say I go to the shop and have only twenty

(rand) on me, I’ll rather buy my wine than bread and milk”.

It is estimated that there are 7 million smokers in South Africa (National Guideline

on stroke and Transient Ischaemic Attack Management, 2001). Smoking can

significantly increase the risk of suffering a recurrent cerebrovascular event as

well as other cardiovascular conditions. This risk may be reduced through

preventative measures, including lifestyle changes such as the cessation of

smoking (Greenlund, Giles, Keenan, Croft & Mensah, 2002).

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Patients therefore need to be made aware of the dangers of smoking and

support programmes should be implemented in order to assist patients to stop

smoking.

The current study assessed that there is a great need to implement programmes

to help stroke patients’ manage their problem of alcohol abuse and smoking.

Such individuals need to be educated on the harm excessive drinking and

smoking has on their general health and well-being and the dangers of them

suffering a recurrent stroke.

5.3.4 Diet modification post-stroke

In the current study approximately 50 % of participants, changed their diet since

having a stroke. Diet can affect stroke risk, with epidemiological studies

indicating an inverse relationship between fruit and vegetable consumption and

cardiovascular events (Goldstein et al., 2001). A study including individuals free

of cardiovascular disease at baseline found that the relative risk of stroke was

reduced by 31% for persons in the highest quintile of fruit and vegetable intake

(Joshipura et al., 1999). Analysis of data from the National Health and Nutrition

Examination Survey Epidemiologic Follow-up Study supports these results

(Bazzano et al., 2002). This study found that consumption of fruit and vegetables

≥ 3 times per day compared with < 1 time per day was associated with a 27%

lower stroke incidence.

Dietary factors that may be related to reduction in stroke risk include increased

antioxidants and potassium through greater consumption of fruits and vegetables

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and reduced salt intake, which may lower high blood pressure, the major risk

factor for stroke (Gariballa, 2000). Barriers for participants in the present study

not changing their diet post stroke included ‘too expensive’, ‘did not know about

the benefits of changing their diet’ and ‘did not know how to change their diet’.

These barriers could be easily overcome if the stroke patient’s received more

adequate information from health professionals (especially dieticians) with

respect to the benefits of eating more fresh fruit and vegetables. Workshops

could even be held where stroke patients are taught different ways to preparing

healthy meals. Individuals who have suffered a stroke must be made aware that

their money will also go further if they buy fresh fruit and vegetables, rather than

unhealthy processed foods and large amounts of meat. Therefore all the above

mentioned barriers to diet are able to be overcome with the sharing of

information.

5.3.5 Compliance with use of medication

The majority of participants in the present study had co-morbid illnesses such as

diabetes and hypertension, which have been identified as known health risk

factors. They therefore have to take regular medication to control these

illnesses. Approximately 88.3% of female and male stroke patients in the current

study had high blood pressure.

In the current study, 94% and 90% of the female and male samples respectively,

used medication for various reasons. A large number of participants admitted

that they did not take their mediation as prescribed due to the following reasons.

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Seventy five percent reported that they ‘forgot’ to take their medicine regularly,

especially if they were living alone. 3.1% complained that health professionals

had never explained to them how they should take their medication, and so they

ceased taking it. A further 3.1% reported that it was never explained to them

how often to take their medication.

In addition environmental barriers also proved important for patients from lower

socio-economic classes who have to use the public health system. Numerous

individuals partaking in the qualitative section of the study mentioned that the

high cost of transport to the hospital or community health centre to collect their

medication; as well as the long waiting times which can be anything up to a five

hour wait to see the doctor for ten minutes, and then a further wait at the

pharmacist for their medication prove, to be significant environmental barriers.

One of the participants stated,

P4: “The clinics are not well run. The lines are very long and move very

slowly. I am too sick and weak to spend my whole day waiting for my

pills. Some months, I just don’t fetch them (the medication)”.

P12: “The government needs to either improve the service delivery at the

Community health centres or come up with another plan. What if there

was a special service started where you order your medicine from the

clinic and then they drop it off for you at your house every month.

(Laughs) sort of like a pizza delivery service! Don’t you think more

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people would take their medicine then?”

Patients use a variety of criteria to determine the value of medication and this

may become a barrier to adherence to medical regimens (Wallenius et al., 1995).

They may place an equal or greater value on competing non-clinical outcomes.

Physical, economic, psychological and social factors influence the use of

medication. Patients often take fewer drugs than required, due to their

experiences with side effects and their symptoms (Wallenius et al., 1995).

Surprisingly none of the stroke patients interviewed in the qualitative part of the

study, expressed any concern about side effects influencing their use of

medication. One of the individual’s did express concern about the possibility of

becoming addicted to the analgesics she took for her frequent headaches, as

expressed in the following quotation.

P8: “I have always suffered from these headaches, even before the stroke.

It worries me that I have become too dependant on the pills (headache

medication). I take about eight everyday, even if I don’ t have a

headache. I know they are bad for me and may be affecting the way my

other more important pills are working”.

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5.4 Support Participants in the study identified social support as a major resource that

facilitated a choice of positive health related behaviours. This consisted of

emotional, instrumental and informational type of support. Sources of support

that were mentioned by participants consisted of family, friends, medical staff

(including physiotherapists, doctors, nurses and social workers) and church

groups. Family and friends were frequently mentioned (especially by the

females) as the main sources of emotional and instrumental support through

ways such as having someone to talk to, being a source of encouragement and

also doing activities together. Many of the participants emphasized the extreme

importance of emotional support to their sense of well-being. Social support has

been reported as an important resource by people with chronic disabling

conditions and physical disabilities including those with stroke, in a number of

studies. For instance, in a study by Hampton (2001), social support was found to

be the most influential factor on quality of life of Chinese adults with spinal cord

injuries. In a study by Stuifbergen and Rogers (1997) individuals with multiple

sclerosis identified social supports as being a major resource which enhances

the choice of health-promoting behaviours.

The importance of social support in a stroke sufferer’s life is further highlighted by

many psychological obstacles that they can encounter. Social isolation, low self-

esteem and anxiety have been reported among numerous people with physical

disabilities including those with stroke (Hogan et al., 2000; Steele et al., 1997;

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Stover, Keller, Cobey & Soheap, 1994). In a study by King (1996), on the quality

of life of long-term stroke survivors, depression was found to be the strongest

predictor of overall, psychological, and health quality of life. This finding supports

the results of several other studies (Ahlsio, Britton, Murray & Theorell, 1984;

Anstrom, Asplund & Astrom, 1992; Niemi et al., 1988). Stuifbergen’s conceptual

model of health promotion and quality of life for people with disabilities further

supports the fact that perceptual factors such as depression will have a negative

effect on one’s quality of life. The high rate of depression supports the need for

follow-up programs that include assessment and interventions to treat

depression.

Literature on social support of stroke patients suggests that decreased social

contact or support could result in emotional mal-adaptation (Friedland & McColl,

1987) and lower life satisfaction (Viitanen, Fugl-Meyer, Bernspang & Fugl-Meyer,

1988). Referrals of survivors to support groups and education of family members

and the wider community on the importance of social support after disability may

help to strengthen support. In addition caregivers have been found to benefit

from counseling on ways of managing their responses to stroke patients, so they

can continue to be supportive over the long term (King, 1996).

According to the findings of this study, informational support was one of the

major resources that influenced the health-related behaviours of stroke patients’.

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Only 30.5% of the stroke patients received information about what a stroke is

from health care professionals. The highest rate of information received was on

‘causes of stroke’ (45.6%), whilst a mere 9.6% were educated about the

complications of stroke and how to manage them. Most alarming of all was that

only 29.7% of stroke patients’ participating in this study, were ever educated

about how to prevent a further stroke by incorporating health-enhancing

behaviours into their lives. Similarly, some studies have reported a lack of

access to relevant information regarding health-promoting behaviours such as

physical activity participation and quitting smoking (Bonohue, 1997; Christman,

Ahijerych & Buckworth, 2001). Furthermore, other individuals with physical

disabilities have reported such information as an essential factor that influences

their engagement in health-promoting behaviours (Stuifbergen & Rogers, 1997).

With regards to sources of informational support, most of the participants in the

present received or sought informational support from medical doctors, with

physiotherapists in second place. Given the importance attached to

informational support from the health care professionals by the participants’,

there’s a need for rehabilitation professionals such as physiotherapists to target

family and friends by involving them early during the rehabilitation process so

that they can access relevant information as one of the strategies for health

promotion intervention.

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In the qualitative findings, informational support was regarded as extremely

important in participants’ choice to engage in various lifestyle behaviours. In a

few cases it facilitated them to quit some health-risk behaviours. As one of the

participants explained,

P7: “My doctor told me about the effects smoking was having on my body. It

scared me to think that my own behaviour could result in me having

another stroke. I stopped smoking a few months back and feel more in

control of my health and life now”.

Therefore, as was found in other studies, informational support in the current

study appeared to be one of the most significant resources that facilitated the

participants’ involvement in various health-promoting behaviours (Rimmer et al.,

2000; Stuifbergen & Rogers, 1997; Stuifbergen & Roberts, 1997).

5.5 Participants’ perceived health-related needs Many participants reported that they desired to attend most of the health

promotion programmes as listed in the questionnaire. A mean percentage of

approximately 43.9% perceived the respective programmes assessed to be

health-enhancing. Surprisingly, this mean percentage was much lower than the

80% of lower limb amputees’ who desired to attend a similar list of health-

enhancing programmes (Mutimura, 2001).

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The highest number of participants desired to attend a programme where

information on how to prevent a further stroke would be the focus. Participants

also desired to learn more about what a stroke is and the causes of a stroke,

whilst others perceived information on how to manage their blood pressure as

being essential. Many participants desired to attain new lifestyle habits to

improve their health. Although many participants perceived all programmes as

fundamental, the highest number of participants did not desire to attend

teachings on how to stop smoking and how to manage their weight more

effectively. Teaching about HIV/AIDS awareness and prevention also featured

as one of the least desired teachings. This was in contrast to the findings of

Mutimura’s (2001) study where the highest number of lower limb amputees

desired to attend teachings about HIV/AIDS awareness and prevention. Bearing

in mind the potential dangers of smoking and the HIV/AIDS epidemic in South

Africa, this finding further reflects the participants’ lack of access to relevant

information or willingness to be educated about these two concepts. Over

saturation of information regarding smoking and HIV/AIDS could also be the

reason why they did not want additional information regarding these topics.

With regards to other programmes participants desired to attend in order to

improve their well-being, most participants felt a need to be educated about how

to prevent secondary complications such as pressure sores and contractures.

One participant on the qualitative study explains further,

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P8: “I was never warned about these sores (pressure sores) and had to be

admitted into hospital to get them treated. If the doctor had told me in the

first place that I would be at risk of getting them (the pressure sores), I

could have taken preventative measures like getting pressure care

cushions. It was a case of getting the information when it was already too

late.”

Others wanted their family and/or caregivers to be educated about stroke. One

participant stated,

P2: “It is important that my family be told more information about stroke so

that they are more sympathetic to my needs and are better empowered to

support me at this difficult time in my life”.

P12: “I forget most of the exercises I do with the physiotherapist. That is

why it is better if my wife also learns to do the exercises. That way she

can help me with my exercises at home”.

Numerous participants considered information relating to the prevention and

management of diabetes as being essential. Health interventions also need to

focus on the development of exercise programmes as one participant explained,

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P4: “I am wheelchair bound and attend a stroke group regularly. The problem

is that I cannot do most of the exercises the others (stroke patients) can

do. This makes me frustrated and depressed. It would be better for me to

be placed in a group where the others also have the same amount

(severity) of stroke as I do”.

Many participants expressed their need to receive guidance on how to cope with

depression and lack of motivation. One participant noted,

P9: “I am very depressed because I feel like I am a burden to my family.

Maybe It would help if I see a psychologist or something, but where do I

find one?”

In addition, patients considered issues like staying physically active in daily

activities as well as teachings about weight management tips.

P5: “Since the stroke five years ago, I have put on ten extra kilos. I would love

to either attend a talk, or receive a pamphlet with tips on how to loose

weight and maybe even low fat recipes which I can experiment t with at

home.”

Comparing these findings with other studies, participants desired to attend

health-promotion services more frequently than disability-related services, and

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participants were specifically interested in access to exercise, and stress

management (Stuifbergen et al., 1990). Furthermore, Edwards (1996) reported

that spinal cord injured patients expressed the need to attend exercise

programmes as an important health promotion need. Individuals with lower limb

amputation were reportedly interested in recreational activities (Legro, Reiber,

Czerniecki & Sangeorzan, 2001).

5.6 Aspects of health promotion

The Ottawa Charter has defined health promotion as ‘the process of enabling

people to increase control over, and to improve, their health. To reach a state of

complete physical, mental and social well-being, an individual or group must be

able to identify and realize aspirations, to satisfy needs, and to change or cope

with the environment’ (WHO 1986). By identifying the health promotion needs

specific to stroke patients, three tools, namely advocacy, enabling and mediation,

can be utilized to achieve effective health promotion and address these needs.

As part of health promotion, advocacy would be aimed at creating conditions

which are favorable through the representation of the rights or needs of

marginalized groups such as those disabled by a stroke. Health promotion

attempts to enable, even the least socially and economically powerful e.g. the

disabled, to achieve their fullest health potential. Mediation implies a coordinated

action between the different sectors providing services to those at risk e.g.

disabled people. The Ottawa Charter prioritizes certain action areas for health

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promotion which include creating supportive environments, strengthening

community action and developing personal skills. Health promotion for stroke

patients, concerns quality of life, and will intervene to encourage healthy living

and working environments which are safe, stimulating, satisfying and enjoyable.

Strengthening community action (such as developing stroke support groups,

launching stroke awareness campaigns), can aid in the promotion of health by

allowing communities to be empowered and take control over their own activities

and future. Health promotion supports personal and social development through

information, education for health and building life skills. This will increase the

options available to people in exercising more control over their own lives.

5.7 Relevance to physiotherapists and other rehabilitation

professionals

Rehabilitation programmes have often focused primarily on instructing physically

disabled individuals in the necessary techniques of mobility and activities of daily

living sometimes neglecting the broader health needs (Carpenter, 1994). The

results of the present study emphasize the importance of rehabilitation

professionals including physiotherapists to broaden their services to include

health promotion interventions in addition to their primary roles of improving

functional independence. These health promotion interventions should include

individualized programmes tailored to the stroke patient’s needs such as identity

and psychosocial adjustment issues, information on activities that stroke patients

can safely participate in and information on the dangers of substance usage.

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Rehabilitation professionals need to recognize that although functional

independence is an important goal, resulting behaviours may be detrimental to

the health and quality of life of patients who have suffered a stroke, if health

promotion interventions are not implemented with urgency. Thus it is of utmost

importance to note that education, social support and identity adjustment among

physically disabled individuals with stroke have a significant impact on the health-

related behaviours that they choose to engage in. Rehabilitation professionals

therefore need to foster positive attitudes among these stroke patients and

motivate them as well as offer relevant information to their family and friends

during the rehabilitation process.

Considering the long period of time that individuals who have suffered a stroke

spend with physiotherapists compared to other health professionals, there exists

a responsibility and window of opportunity for the physiotherapist to initiate

individualized health promotional strategies, early in the rehabilitation

programme. These health promotion strategies should be designed to address

all aspects of the stroke patients’ individual needs including self-perception,

psychosocial adjustment issues and health education. In addition it is important

that physiotherapists and other rehabilitation professionals prepare individuals

who have suffered a stroke for the attitudinal barriers that they will face once they

are re-integrated back into society. Rimmer (1999) recommends a greater need

to involve physically disabled individuals, and provide them with more attention

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since they are the most vulnerable members in society. Given the urgency of the

matter, policy makers need to focus their attention on promoting wellness-

enhancing behaviours. In a recent review, Stanley (2001) indicated how vital it is

to promote well-being through education, behavioural change and research

involving the most vulnerable groups of people in society.

The essence of health promotion is an active and self-care strategy. Health care

professionals should be involved, only to advise people with physical disabilities

on the appropriate health-promoting behaviours. People with physical disabilities

should spearhead all fundamental processes, including behavioural change,

which seeks to promote and improve their quality of life.

The holistic approach to health promotion and behavioural change is a

challenging one. Intervention strategies should take into account the interaction

of major tasks to reverse the current situation. Educational programmes for

stroke patients should be conducted at the most easily accessible places in the

community such as the various community health centres, church or community

halls. Educational programmes should be integrated into both existing and newly

established stroke groups thereby exposing the individual to a holistic approach

which incorporates both their physical and educational needs. The media should

also become involved in strengthening community action by including

educational programmes in magazines, newspapers and even on the radio.

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Utilizing the radio to promote health behaviours of lower limb amputees in

Rwanda, proved very effective (Mutimura, 2001).

However, one-to-one talks held by clinicians and rehabilitation therapists are

more highly recommended. Zellwelder (2001) recommended that the one-to-one

method be included in the promotion of appropriate healthy behaviours, such as

the cessation of smoking in the daily practice of health care providers.

Furthermore, Parrot, Godfrey and Raw, (1998) emphasized the usefulness and

cost-effectiveness of one-to-one talk in health intervention against health-risk

behaviours including alcohol abuse.

Health promotion interventions that encourage participation in health-promoting

behaviours would certainly improve the quality of life of stroke patients’.

Interventions would seek to include all people with physical disabilities. Such

interventions would help to ameliorate or alleviate the effect of both the disability,

modify certain risk factors, and set a path for a better quality of life in the future

(Mutimura, 2001). Zajicek and Michaela (1998) suggested that health care

professionals increase their commitment to promoting healthy lifestyles with a

view to enhancing the disabled individuals’ self-direction in making optimal life

choices.

An interdisciplinary approach is vital to the successful implementation of health

promotion strategies. Such an approach would need to maintain strong linkages

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to research, evaluating the successes and failures of the programmes. Taking

into account that some health promotion programmes, for example stroke groups

providing exercises and information relating to stroke, have already been

implemented at some Community Health Centres in the Western Cape, the

current study serves as a ‘process evaluation’ for health promotion interventions

among stroke sufferers.

Despite the possible constraints in resources, valuations of programme activities

need to encompass process evaluation, impact and outcome assessments

(Mutimura, 2001). According to Coulson, Goldstein and Ntuli (1998), both impact

and outcome evaluations are essential in health promotion. In impact evaluation,

the immediate effects of the interventions are often determined to ensure that the

activities or interventions have the desired effects. Naidoo and Wills (2000),

however mainly commend outcome evaluations. Although outcome evaluations

are more costly and complex, these evaluations are more reliable since they

indicate maintained changes over a longer period of time. In the majority of

cases, outcome evaluations need to encompass control groups of participants

who did not receive the interventions. Therefore the possibility of attributing all

lifestyle behavioural changes to particular interventions is avoided.

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Conclusion and Recommendations Health promotion needs of stroke patients

CHAPTER SIX

SUMMARY, CONCLUSIONS, LIMITATIONS AND

RECOMMENDATIONS

6.1 Introduction

In this final chapter, a brief summary of the study is provided. Details of the

major issues in the study are given in the conclusion, limitations are discussed

and thereafter recommendations arising from the study are proposed.

6.2 Summary

This study aimed to determine the health promotion needs of stroke patients’

accessing community health centres in the Metropole region of the Western

Cape. The study specifically explored the participants’ health-related behaviours,

factors that influenced their behaviours, and major issues that needed to be

targeted in health promotion.

The study was carried out on the basis that there is a paucity of information

regarding people with physical disabilities (including stroke sufferers) in South

Africa. As a result the issues surrounding health promotion of these disabled

individuals has not been significantly explored. Due to the presence of a primary

disability, individuals who have suffered a stroke are at a significant risk for the

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development of secondary complications such as pressure sores, contractures

and emotional disorders. In addition, poor choices of lifestyles, such as physical

inactivity and substance usage can further result in a deterioration of their status

in life. Rehabilitation services have traditionally been designed mainly for

individuals experiencing sudden on-set traumatic disabling conditions. Despite

the potential of the rehabilitation process to impact on the disabled individuals’

lifestyles, very few programmes have focused on issues to minimize the

secondary complications of stroke by promoting health-enhancing behaviours.

This has resulted in the physically disabled, especially those who have suffered a

stroke, to face major challenges of promoting and maintaining their quality of life

with little or no help from health care professionals (Stuifbergen & Rogers, 1997).

The findings of this study indicate that most of the participants were indeed

involved in risky health behaviours including sedentary lifestyles and substance

usage such as alcohol and smoking. Numerous factors were identified, that had

an influence on the participant’s choice of the behaviours that they were involved

in. These factors included barriers such as lack of access to relevant information

and psychosocial difficulties associated with the adjustment to a new identity.

Rehabilitation professionals therefore need to assume the roles of partnership

with stroke patients to educate, research and provide relevant information about

health promotion and how to overcome the identified barriers to health

behaviours.

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6.3 Conclusion

This study revealed that individual’s who have suffered a stroke, had a number of

health promotion needs, mainly resulting from their health-related behaviours.

The findings of this study indicate that participants were involved in health risk

behaviours, such as being physically inactive, smoking, consuming alcohol, not

taking medication as prescribed by the doctor, and unhealthy eating habits.

Health risk behaviours such as these are associated with the development of

secondary complications such as pressure sores and contractures.

In addition, participants were vulnerable to emotional disorders due to low

psycho-social status and self-perception. These appeared to be indicators of

poor-socio-economic status and well-being, which could have likely predisposed

to alcohol consumption or smoking. The qualitative findings indicated that such

psych-social symptoms adversely increased participants’ involvement in

substance usage.

It can therefore be concluded that the impact of such lifestyle behaviours was

detrimental to the participants’ health status. Health promotion programmes,

focusing on the identified health promotion needs of stroke patients, need to be

implemented by health professionals as this would result in more patient

centered, holistic rehabilitation services. Rehabilitation programmes

encompassing health promotion will promote social and economic community

development, particularly by empowering the disabled individual, their care-

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givers and family. This will aid in reducing South Africa’s health, welfare and

economic burden, as a result of disabilities such as stroke.

6.4 Limitations of the study

1. Although a reasonably large number of stroke patients participated

in this study, a response bias cannot be completely overlooked. The

researcher included participants from all of the health districts, as

well as from various socio-economic backgrounds in the current study

for purposes of equal representation. However, despite these attempts,

the study can only provide a generalization of the health promotion

needs of stroke patients in the Metropole region of the Western Cape.

2. The questionnaire could not assess certain issues. For example, it could only

assess the frequency of participation in physical activity or exercise but

did not assess the intensity of participation.

3. Substance usage, which assessed the number of cigarettes smoked daily and

frequency of alcohol consumption, did not include the frequency of illegal

drug use.

4. Purposive sampling was used to select the participants for the qualitative

part of the study. A smaller sample was preferred because of the kind of

in-depth information gathered. The findings of the qualitative study cannot be

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generalized to all individuals physically disabled as a result of stroke.

5. All qualitative interviews were in the English language. This may have

limited the participants’ expressions as opposed to if their own native

language had been used.

Despite these few limitations, the study revealed some interesting insights

about the issues surrounding the health promotion needs of stroke patients

accessing community health centres in the Metropole region of the Western

Cape.

6.5 Recommendations

Based on the findings of this study, a number of recommendations are made:

1. It is recommended that rehabilitation professionals expand their services

to include individualized health promotion strategies in the rehabilitation

programmes of individuals who have suffered a stroke.

Physiotherapists in particular, have window of opportunity for initiating health

promotion interventions early in the rehabilitation programme. These health

promotion interventions need to initially, be incorporated into the treatment

goals of these individuals so as to address the specific needs of each

individual. Once the stroke patient has completed the rehabilitation

programme, follow-up workshops in the community can be organized to

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assist in the formation of support groups where any questions can be

answered, and progress can be monitored. Workshops such as these will

ensure continuity of the health promotion practices.

2. Health care professionals, particularly physiotherapists, have an obligation

to set up health promotion interventions aimed at increasing awareness

of health-risk behaviours, such as physical inactivity, smoking, and

alcohol consumption. All individuals with physical disabilities, particularly

those who have suffered a stroke, should be encouraged to refrain from

alcohol consumption, smoking and being physically inactive. It is often

suggested that people should ‘start exercising and quit smoking’, in order to

prevent a wide range of chronic disease of lifestyle. Secondly, health

promotion interventions need to aim at identifying other health-risk behaviours

of stroke patients.

3. Access to relevant information was found to be an important resource

influencing participants’ behaviours. Therefore, health care professionals

need to empower physically disabled individuals with information to

encourage health-promoting behaviours, while at the same time prevent

health-risk behaviours. For example, adequate basic information needs to

be offered to stroke patients’ on how to prevent pressure sore

development, which can significantly affect the quality of life of the

individual. Practising health-promoting behaviours such as pressure

162


control, becoming more physically active and proper hygiene will help

prevent such a secondary complication from developing.

4. Social support was found to be an important resource for choice of positive

health-related behaviours. Given the importance attached to emotional

support from family and friends, it is highly recommended that family and

friends of stroke sufferers are involved from the commencement of the

rehabilitation process. It is further recommended that informational support

be aimed at increasing awareness about stroke, such as the causes and

prevention of stroke, how to avoid health-risk behaviours which could expose

one to further secondary complications, and how to take control over ones’

health by practicing health-promoting behaviours. This information should

also be availed to family, caregivers and close friends for sustenance.

5. A number of factors influenced participation in health-related behaviours. The

majority of participants reported a number of barriers to health-promoting

behaviours. One such example is the high cost of transport, which prevents

many individuals with stroke attending stroke groups where they can partake

in health-promoting activities such as physical exercises. A suggestion made

by one of the participants is that the government operates an exclusive free

‘taxi service’ for disabled individuals in the communities. Disabled individuals

should be able to book a place on the ‘taxi’, and it should transport them

from their homes, to their respective health care appointments/ treatments

163


and back home again. A similar delivery service was also recommended,

where repeat medication could be delivered to the stroke patients’ home if

they did not have access to transport. Therefore the above

recommendations would aid in alleviating or eliminating such barriers.

6. It is further recommended that health policy makers consider the use of

resources upstream, integrating health promotion and the prevention of

complications into the rehabilitation process, instead of using resources

only for expensive downstream care, after certain complications are

irreversible.

7. The issues that were raised by the individuals who had suffered a stroke

in this study, need to be studied further using a larger sample size.

Studies need to focus more on the precise health-promoting behaviour

profiles such as the physical activity of specific subgroups of individuals

with physical disabilities. In addition, studies need to specifically

establish barriers and determinants of involvement in various health-

related behaviours. Future studies need to design and test intervention

strategies to promote the various health-promoting behaviours.

8. An exploratory in-depth qualitative study is recommended to enhance the

understanding of issues related to participants self-perception and

involvement in health-risk behaviours.

164


9. The various health promotion needs of stroke patients’ identified in the

present study, must be incorporated in health promotion programmes,

specifically developed for stroke patients.

165

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Patient Information / Consent Form Health Promotion Needs of Stroke Patients accessing Community Health Centres in the Metropole Region, of the Western Cape Reference Number: Statement by or on behalf of the participant; I the undersigned, ……………………………… person who has suffered a stroke * or in my capacity as ……………………………….. of the person who has had a stroke staying at …………………………………… acknowledges that: 1. I have been invited to partake in a study, which forms part of a Master’s thesis undertaken at the University of the Western Cape.

2.1 It has been explained to me that the aim of the study is to determine the health promotion needs, through identification of the health-related behaviours of stroke patients receiving rehabilitation at the Community Health Centres in the Metropole Region of the Western Cape.

2.2 It has been explained to me that the study consists of two parts: Part 1: Information relating to your stroke, as well as your health-related behaviours and influencing factors, will be collected using a once off questionnaire. Part 2: Consists of a face-to-face interview with the researcher. The interview will be tape recorded and only twelve patients who have fully completed the questionnaire will be considered for the interview. Your privacy is guaranteed. 2.3 All data collected from the questionnaires and interviews will be treated with great respect to ensure my privacy. Every participating patient will get a code and confidentiality will be guaranteed.

2.4 It has been explained to me that I will not be incurring any additional costs by partaking in this study, and will not benefit financially from it. 2.5 It has been explained to me that the findings of this study will be presented in a thesis and could be published in a professional journal or presented as a professional report.

3. Voluntary and informed consent

I have the ability to understand the information on these pages and I choose freely to participate in this project. I have been informed that I am free to withdraw from this project at any time. This will have no consequences for my future treatment at the center or in other hospitals. Signed ……………………………….. Date ………………………….. Researcher …………………………… Date ……………………….....

QUESTIONNAIRE #

SECTION A : SOCIO-DEMOGRAPHIC DATA Please tell us about yourself

1. Age

2. Gender Female Male

3. Marital status (You may mark more than one option)

Single Married Divorced Separated Widowed Living together

4. Highest educational qualification (Fill applicable spaces)

None Sub Std Higher than Std 10 (Matric)

5. Were you employed at the time of your stroke? Yes No

If you answered yes, please answer question 6.

6. What type of work did you do?

7. Are you currently employed? Yes No

8. If yes, what work do you do now?

9. If no, why are you not employed? (Tick appropriate option)

Retired receiving pension Illness or disability (no disability grant)

Illness or disability (receiving disability grant) Unemployed

Looking after the home, no benefits

Other, please specify

10. How did you spend most of your days, over the past week? (Tick appropriate option/s)

Visiting family/friends Watching T.V.

Doing chores around the house Doing nothing


11. Where are you currently living?

My own house With a member of my family

Rented-house Old age home


12. Which area do you live in?

13. Do you have access to transport? Yes No

14. If yes, mark below what you normally use

Public transport (taxi, bus, train) Private transport

15. If no, what do you do if you have to go somewhere?

Walk Use a wheel-chair Forced to stay at home


SECTION B : INFORMATION RELATING TO STROKE

16. How long ago did you have a stroke?

Less than 3 months ago 3 to 6 months ago

More than 7 months ago but less than 12 months

More than 12 months ago

17. What side of your body is affected? (Tick appropriate option)

Left Right Both

18. Were you admitted to hospital at the time of having the stroke? (Tick appropriate option)

Yes No

19. If your answer was yes, which hospital? (Mark the appropriate block)

Tygerberg Groote Schuur Somerset

Victoria G.F. Jooste False Bay

Eersterivier Hottentots Holland Stellenbosch

Westfleur Private Hospital


20. Were you admitted to a centre for rehabilitation? (Tick appropriate option)

Yes No

21. If you answered yes, where were you admitted?

Western Cape Rehabilitation Centre Panorama

Conradie Care Centre Booth Memorial


22. How long did you stay at the rehabilitation centre?

Less than one week One week Between one and two weeks

Between two and three weeks Between three and four weeks

Longer than four weeks

23. Have you ever received any rehabilitation services?(e.g. physiotherapy, occupational therapy, speech therapy)

Yes No

If you answered yes, please answer questions 24 & 25.

24. What rehabilitation services did you receive? (Tick appropriate option/s)

Physiotherapy Occupational Therapy Speech Therapy


25. Where did you receive rehabilitation services? (Tick appropriate option/s)

Hospital Community Health Centre


SECTION C : GENERAL HEALTH/LIFESTYLE

26. Do you smoke cigarettes at present?

Yes No

27. If yes, about how many cigarettes do you smoke each day?

1 - 5 6 - 10 11 - 20 21 - 30 Over 30

28. Did you smoke at the time of your stroke?

Yes No

29. If you smoked at the time of your stroke but no longer do,what made you stop smoking?

30. Do you drink alcoholic drinks at present?

Yes No

31. Did you drink alcohol at the time of your stroke?

Yes No

32. If you used to drink alcohol at the time of your stroke but no longerdo, what made you stop drinking?

33. If you answered yes to question 30, what alcohol do you normally drink?

Beers Spirits Wine


34. How much alcohol do you drink at one time on average?

One can of beer Two cans of beer Three or more cans of beer

One tot Two tots Three tots More than three tots

One glass of wine Two glasses of wine More than two glasses of wine


35. How often do you drink these alcoholic drinks per week?

Everyday 3 - 4 times Once a week

A few times a month Hardly ever or never

36. Have you changed your eating habits / diet since having the stroke?

Yes No

37. If no, what are the reasons for not changing your diet?

Too expensive Did not know about changing my diet

Don't know how to change my eating habits/diet


38. Do you have any of the following illnesses? (Tick relevant option/s)

Diabetes Hypertension/High blood pressure

Cardiac/Heart problems Obesity/Overweight


39. Are you taking any medicine / tablets?

Yes No

40. What are you taking the medicine / tablets for?

41. Do you take your medicine / tablets as prescribed? (Tick appropriate option)

Yes No Sometimes

42. If you answered no, or sometimes, what are your reasons?

I forget Was never explained to me how I should take my medication

Was never explained to me how often I should take my medication


SECTION D : KNOWLEDGE ABOUT STROKE

43. Were you ever given any information about stroke from health care professionals?

Yes No

44. If yes, who told you the information? (Tick relevant option/s)

Doctor Physiotherapist Community health worker

Occupational Therapist Speech Therapist Nurse


45. What information were you given about stroke? (Tick relevant option/s)

What is a stroke Causes of stroke How to prevent a further stroke

How to prevent secondary complications such as pressure sores, contractures etc.


SECTION E : SUPPORT

46. What support (emotional & physical) do you feel you need since having a stroke?(emotional : e.g. do you need motivation and encouragement when you are feeling down?)( physical : e.g. do you need extra help with bathing, dressing, or anything else around the home?)

47. Who do you think should be providing this support?(Tick relevant option/s)

Stroke group Family/friends Church group Medical staff


48. Do you feel you receive the support you need post stroke?

Yes No

49. If you do not attend a stroke group, what are the reasons for this?

Transport is too expensive No stroke group close to where I live

Didn't know about stroke groups Don't need to attend a stroke group


SECTION F : PHYSICAL MOBILITY

50. Are you receiving any form of physiotherapy at the moment?

Yes No

51. If you answered yes, is your physiotherapy treatment on an individual or group basis?

Individual Group

52. Do you participate in any kind of physical activity or exercises like walking, gym,exercising in a stroke group on a regular basis, for half an hour each time?

Yes No

53. If you answered yes, what exercises do you do?

54. How often do you participate in physical activity for at least half an hour each time?

Everyday 3 times a week Once a week

Few times a month Hardly ever or never

55. If you do not participate in any kind of physical activity, what are the reasons?(Tick appropriate answer/s)

Cost of transport Do not know where to exercise Lack of motivation

Have other health concerns Lack of energy/not sure I can manage


56. Are you doing exercises at home to prevent stiffness as a result of stroke?

Yes No

57. Do you check the skin of your affected side for pressure sores, on a regular basis?

Yes No

SECTION G : PERCEIVED HEALTH-RELATED NEEDS

Please tell us what programmes you would like to learn more about, in order to improve your well-being.

Tick the programme/s you are interested in:

Explanation about what stroke is and the causes of stroke

Information on how to prevent a further stroke

Teaching how to prevent pressure sores and contractures

Educating family members/caregivers about stroke

Guidance on how to cope with depression and lack of motivation

Teaching about exercise options and programmes

Teaching about weight management tips

How you can stay physically active in daily activities

Prevention/management of diabetes and hypertension

Teaching how to manage stress

Teaching how to stop smoking

Your blood pressure and what you can do about it

Learning about new ways to improve your health

Teaching about HIV/AIDS awareness and prevention

State anything else you would like to be taught to improve your well-being.

Thank you for your participation.

Pasiënt Inligting / Toestemmingsvorm Behoeftes vir Gesondheidsbevordering van Beroete pasiënte wat toegang tot Gemeenskapgesondheidsentrums in die Metropoolarea van die Wes-Kaap verkry Verwysingsnommer: Verklaring deur of namens die deelnemer: Ek, die ondergetekende, ……………………………………….. persoon wat ‘n beroerte-aanval gehad het * of in my hoedanigheid as …………………………….. van die persoon wat ‘n beroerteaanval gehad het en by …………………………………………… woon erken dat:

1. Ek genooi is om deel te neem aan ‘n studie wat deel vorm van my Meestersgraad tesis, onderneem deur die Universiteit van die WesKaapland. 2.1 Dit is aan my verduidelik dat die doel van die studie is om behoeftes van gesondheidsbevordering te bepaal deur identifisering van die gesondheidsverwante gedragspatrone van beroerte pasiënte wat rehabilitasie by die Gemeenskapgesondheidssentrums in die Metropoolarea in die Wes-Kaap ontvang. 2.2 Dit is aan my verduidelik dat die studie uit twee dele bestaan: Deel 1: Inligting rakende die beroerte-aanval, sowel as jou gesondheidsverwante gedragspatrone en inwerkende faktore sal versamel word deur ‘n eenmalige vraelys te gebruik. Deel 2: Bestaan uit ‘n persoonlike onderhoud met die navorser. Die onderhoud sal op band opgeneem word en slegs twaalf pasiënte ten volle die vraelys voltooi het, sal vir die onderhoud oorweeg word. U privaatheid word gewaarborg. 2.3 Alle versamelde data van die vraelyste en onderhoude sal met die grootste respek behandel word om privaatheid te verseker. Elke deelnemende pasiënt sal ‘n kode kry en vertroulikheid word gewaarborg.

2.4 Dit is aan my verduidelik date k geen addisionele onkoste sal aangaan deur aan die studied eel te neem nie en ook nie finansieel daarby sal baat nie.

2.5 Dit is aan my verduidelik dat die bevindinge van di studie in ‘n tesis voorgelê sal word en dat dit ‘n professionele joernaal gepubliseer of as professionele verslag aangebeid kan word.

2. Vrywillige en ingeligte toestemming Ek het die vermoë om die inligting op hierdie bladsye te verstaan en ek kies vryelik om aan hierdie projek deel te neem. Ek is ingelig date k vry is om enige tyd van die projek te onttrek. Dit sal geen gevolge vir my toekomstige behandeling by die sntrum of enige ander hospitale inhou nie. Geteken ……………………………. Datum ………………………… Navorser ……………………………. Datum ………………………..

VRAELYS #

AFDELING A: SOSIO-DEMOGRAFIESE DATA Vertel ons asseblief van uself

1. Ouderdom

2. Geslag Vroulik Manlik

3. Huwelikstatus ( u mag meer as een opsie merk)

Enkel Getroud Geskei Weduwee/Wewenaar Woon saam

4. Hoogste opvoedkundige kwalifikasie (Voltooi toepaslike spasies)

Geen Sub St. Hoër as St.10 (Matriek)

5. Het u met die beroerte-aanval gewerk? Ja Nee

Indien ja, beantwoord asseblief Vraag 6.

6. Watter soort werk het u gedoen?

7. Het u op die oomblik werk? Ja Nee

8. Indien ja, watter tipe werk doen u?

9. Indien nee, waarom werk u nie? ( Tik gepaste opsie)

Afgetree ontvang pensioen Siekte of ongeskiktheid (geen ongeskiktheidstoelae)

Siekte of ongeskiktheid (ontvang ongeskiktheidstoelae) Werkloos

Sien na die huis om, geen voordele /vergoeding nie

Ander, dui asseblief aan

10. Hoe het u die meeste van u dae oor die afgelope week deurgebring?(Tik gepaste opsie/s)

Besoek familie/vriende Kyk TV

Doen werkies rondom die huis Doen niks nie


11. Waar woon u tans?

My eie huis Met 'n familielid

Gehuurde huis Oue-tehuis


12. In watter area woon u?

13. Het u toegang tot vervoer? Ja Nee

14. Indien ja, dui hier onder aan wat u normaalweg gebruik

Openbare vervoer (taxi, bus, trein) Private vervoer

15. Indien nee, wat doen u indien u êrens moet gaan?

Stap Gebruik rolstoel Genoodsaak om tuis te bly


AFDELING B : INLIGTING MET BETREKKING TOT BEROERTE

16. Hoe lank gelede het u die beroerte gehad?

Minder as 3 maande gelede 3 tot 6 maande gelede

Meer as 7 maande gelede, maar minder as 12 maande

Meer as 12 maande gelede

17. Watter kant van u liggaam is geaffekteer? (Tik gepaste opsie)

Linkerkant Regterkant Linkerkant en regterkant

18. Is u in 'n hospitaal opgeneem tydens u beroerte-aanval? (Tik gepaste opsie)

Ja Nee

19. Indien u antwoord "Ja" was, watter hospitaal was dit? (Merk gepaste blokkie)

Tygerberg Groote Schuur Somerset

Victoria G.F. Jooste Valsbaai

Eersterivier Hottentots Holland Stellenbosch

Westfleur Privaat Hospitaal


20. Is u in 'n rehabilitasiesentrum opgeneem? (Tik gepaste opsie)

Ja Nee

21. Indien u "Ja" geantwoord het, waar is u opgeneem? (Tik gepaste opsie)

Wes-Kaap Rehabilitasiesentrum Panorama

Conradie Sorgsentrum Booth Gedenk


22. Hoe lank het u in die rehabilitasiesentrum gebly?

Minder as 'n week Een week Tussen een en twee weke

Tussen twee en drie weke Tussen drie en vier weke

Langer as vier weke

23. Het u al voorheen enige van die rehabilitasiedienste hier onder gekry?(e.g. fisioterapie, beroepsterapie, spraakterapie)

Ja Nee

Indien u "Ja" geantwoord het, doen asseblief 24 & 25.

24. Watter rehabilitasiedienste het u gekry? (Tik gepaste opsie/s)

Fisioterapie Beroepsterapie Spraakterapie


25. Waar het u die rehabilitasiedienste gekry? (Tik gepaste opsie/s)

Hospitaal Gemeenskaps-gesondheidsentrum


AFDELING C: ALGEMENE GESONDHEID/LEWENSWYSE

26. Rook u tans sigarette?

Ja Nee

27. Indien "Ja", hoeveel sigarette rook u per dag?

1 - 5 6 - 10 11 - 20 21 - 30 Meer as 30

28. Het u tydens die beroerte-aanval gerook?

Ja Nee

29. Indien u tydens die beroerte-aanval gerook het, maar nie nou meer nie,wat het u laat ophou rook?

30. Drink u tans alkoholiese drankies?

Ja Nee

31. Het u alkohol tydens die beroerte-aanval gedrink?

Ja Nee

32. Indien u tydens die deroerte-aanval alkohol verbruik het, maar nie nou meer nie, wat het u laat ophou drink?

33. Indien u 'Ja' op vraag 30 geantwoord het, watter soort alkohol het u normaalweggedrink?

Biere Spiritus Wyn


34. Hoeveel alkohol drink u gemiddeld op een slag?

Een blikkie bier Twee blikkies bier Drie of meer blikkies bier

Een sopie Twee sopies Drie sopies Meer as drie sopies

Een glas wyn Twee glase wyn Meer as twee glase wyn


35. Hoe dikwels per week drink u hierdie alkoholiese drankies?

Elke dag 3 - 4 keer Een keer per week

n Paar keer 'n maand Amper nooit of nooit nie

36. Het u van eetgewoontes/dieet verander tydens die beroerte-aanval?

Ja Nee

37. Indien nee, om watter redes het u nie u dieet verander nie?

Te duur Het nie geweet van dieetverandering nie

Weet nie hoe om my dieet/eetgewoontes te verander nie


38. Het u enige van die volgende siektes? (Tik relevante opsie/s)

Diabetes Hipertensie/ Hoëbloeddruk

Kardiale/Hartprobleme Obesiteit/Oorgewig


39. Neem u enige medikasie/tablette?

Ja Nee

40. Waarvoor neem u medikasie?

41. Neem u die medikasie soos voorgeskryf? (Tik gepaste opsie)

Ja Nee Soms

42. Indien u 'nee' of 'soms' geantwoord het, wat is u redes daarvoor?

Ek vergeet Dit is nooit aan my verduidelik hoe om my medikasie te neem nie

Dit is nooit aan my verduidelik hoe dikwels ek my medikasie moes neem nie


AFDELING D : KENNIS OMTRENT BEROERTE

43. Het u ooit inligting oor beroerte van professionele gesondheidsorgbeamptes ontvang?

Ja Nee

44. Indien "Ja", wie het die inligting verskaf? (Tik relevante opsie/s)

Geneesheer Fisioterapeet Gemeenskaps-gesondheidswerker

Beroepsterapeet Spraakterapeet Verpleegster


45. Watter inligitng het oor beroerte gekry? (Tik relevante opsie/s)

Wat is beroerte Oorsake van beroerte Hoe om beroerte-aanval te voorkom

Hoe om sekondêre komplikasies soos druksere, sametrekkings, ens. te verhoed


AFDELING E : ONDERSTEUNING

46. Watter ondersteuning (emosioneel en liggaamlik), dink u, het u sedert u beroerte-aanval nodig?

47. Wie, dink u, moet hierdie ondersteuning verskaf?

Beroerte-groep Familie/vriende Kerkgroep Mediese personeel


48. Dink u dat u hierdie ondersteuning na die beroerte kry?

Ja Nee

49. Indien u nie 'n beroerte-groep bywoon nie, wat is die redes daarvoor?

Vervoer is te duur Geen beroerte-groep naby my woonplek nie

Het nie geweet van beroerte-groepe nie Hoef nie beroerte-groep by te woon nie


AFDELING F : FISIESE BEWEEGLIKHEID

50. Kry u tans enige fisioterapie?

Ja Nee

51. Indien u "Ja" geantwoord het, is die fisioterapie op 'n individuele of groepbasis?

Individueel Groep

52. Neem u op 'n gereelde basis, vir 'n halfuur elke keer, aan enige fisiese oefening soosmuuroefeninge in 'n beroerte-groep deel?

Ja Nee

53. Indien u "Ja" geantwoord het, watter oefeninge doen u?

54. Hoe dikwels neem u aan fisiese aktiwiteite, vir ten minste 'n halfuur elke keer, deel?

Elke dag 3 maal 'n week Een keer 'n week

n Paar maal 'n maand Amper nooit of nooit nie

55. Indien u nie aan enige tipe fisiese aktiwiteit deelneem nie, wat is u redes?(Tik gepaste opsie/s)

Koste van vervoer Weet nie waar om te gaan oefen nie Gebrek aan motivering

Het ander gesondheidsprobleme Gebrek aan energie/ onseker of ek dit sal kan hanteer


56. Doen u tuis oefeninge om styfheid as gevolg van die beroerte te voorkom ?

Ja Nee

57. Ondersoek u op 'n gereelde basis die vel van die geaffekteerde kant vir druksere?

Ja Nee

AFDELING G : WAARGENOME GESONDHEIDSVERWANTE BEHOEFTES

Lig ons asseblief in van watter program/me u meer wil leer om u welstand te verbeter.

Tik die program/me waarin u belangstel:

Verduideliking wat beroerte is en die oorsake daarvan

Inligting hoe om beroerte te voorkom

Leer hoe om druksere en sametrekkings te voorkom

Lig familielede/versorgers in oor beroerte

Leiding oor hoe om depressie en gebrek aan motivering te hanteer

Leer van oefening opsies en programme

Leer van gewigsbeheerwenke

Hoe u in daaglikse aktiwiteite fisies aktief kan bly

Voorkoming/ Beheer van diabetes en hipertensie

Leer van stresbeheer

Leer hoe om op te hou rook

U bloeddruk en wat u daaromtrent kan doen

Leer van nuwe maniere om u gesondheid te verbeter

Leer van MIV / VIGS-bewustheid en voorkoming

Meld enige iets anders wat u graag wil leer om u welstand te verbeter

Dankie vir u deelname.

Ulwazi ngoMguli / Ifomu yokunika imvume Iimfuno zokuphuculwa kweMpilo yabagula si-stroke benokufikelela kumaziko eMpilo kwiNgingqi yeSixekokazi, eNtshona Koloni INombolo yeSalathiso: Ingxelo eyenziwa ngumthathi-nxaxheba okanye eyenziwa egameni lakhe; Mna, lo usayine apha ngezantsi, ………………………………nothe wahlaselwa si-stroke * okanye ngokwegunya endinalo njenge/o ………………………..womguli ohlaselwe si-stroke, nohlala …………………………………………… ndiyavuma ukuba:

1. Ndibiziwe ukuba ndithabathe inxaxheba kuphando, oluyinxalenye yethisisi yezifundo zeeMasters, eziqhutyelwa kwiYunivesithi yeleNtshona Koloni.

2.1 Ndiye ndacaciselwa ukuba injongo yolu phando kukufumana iimfuno zezempilo, ngokuthi kuchongwe iindlela ezithile zokuziphatha zabantu abahlaselwe si-stroke, nabafumana unyango kumaZiko ezeMpilo yoLuntu kwiNgingqi yeSixekokazi kwiPhondo leNtshona Koloni.

2.2 Ndicaciselwe ukuba olu phando lunezigaba ezibini:

ISigaba sokuqala:

Ulwazi ngokuphathelene ne-stroke sakho, kunye neendlela zokuziphatha ezinxulumene nempilo, kunye nezinto ezinefuthe, luya kuthi luqokelelwe kusetyenziswa iphepha lemibuzo elinye kuphela.

ISigaba 2:

Sinodliwano-ndlebe olwenziwa ngqo nguMpandi. Olu dliwano-ndlebe luza kushicilelwa ze kuqwalaselwe kuphela abaguli abali-12 abathe bagcwalisa ngokupheleleyo amaphepha emibuzo. Uyaqinisekiswa ngobumfihlelo beempendulo zakho. 2.3 Lonke ulwazi oluqokelelweyo kwiphepha lemibuzo luya kuhlonelwa kakhulu ukuqinisekisa ubumfihlelo. Wonke umguli othabatha inxaxheba uya kufumana inani eliyimfihlo ze kuqinisekiswe ubumfihlelo.

2.4 Ndicaciselwe nokuba andiyi kuzenzela tyala lingaphezulu ngokuthi ndithabathe inxaxheba kolu phando, yaye andiyi kufumana nanzuzo kulo.

2.5 Ndicaciselwe nokuba iziphumo zolu phando ziya kunikezelwa kwithisisi, yaye zisenokupapashwa kwiphepha-ndaba elisisigxina.

3. Isivumelwano esinganyeliswanga nesenziwa ngonolwazi. Ndiyakwazi ukuluqonda ulwazi olukula maphepha yaye ndizikhethele ukuthabatha inxaxheba kule projekthi. Ndazisiwe ukuba ndinakho ukurhoxa kule projekthi nangalo naliphi ithuba. Oko akuyi kuchaphazela unyango lwango lwam kwixa elizayo kwiziko lezonyango okanye nasiphi na esinye isibhedlele. Isayiniwe:……………………………. Umhla:………………………..

UMphandi…………………………….. Umhla:……………………….

IPHEPHA LEMIBUZO #

ICANDELO A: ULWAZI NGENTLALO NAMANANI ABANTU ABAZELWEYO ABABHUBHILEYO NABAGULAYO NJALO NJALO Nceda usixelele ngawe

1. Ubudala

2. Isini ndingowasetyhini ndingumntu oyindoda

3. Ubume bomtshato (ungaphawula ngaphezulu kwesinye)

anditshatanga nditshatile Ndahlukene nomlingane wam ndahlukene neqabane lam

ndaswelekelwa liqabane lam ndiyahlalisana

4. Elona banga liphezulu uliphumeleleyo esikolweni (Vala izikhewu ezifanelekileyo)

Alikho Liphantsi Ibanga Ngaphezulu kwebanga le-10 (i-Matric)

5. Ingaba wawuphangela ngethuba ufunyanwa si-stroke ? Ewe Hayi

Ukuba uphendule ngo-ewe, nceda uphendule umbuzo 6.

6. Wawusenza msebenzi mni?

7. Uyasebenza xa kungoku? Ewe Hayi

8. Ukuba uyasebenza, wenza msebenzi mni?

9. Kutheni ungasebenzi nje?

Ndithathe umhlala phantsi, ndamnkela indodla

Kungenxa yesigulo okanye ukukhubazeka (andifumani ndodla yokukhubazeka)

Ngenxa yokugula okanye ukukhubazeka (ndamkela indodla yokukhubazeka) Andiphangeli

Ndijonge ikhaya, andifumani zibonelelelo

Esinye isizathu, nceda ucacise

10. Uluchithe njani uninzi lweentsuku zakho, kule veki iphelileyo? (Phawula impendulo efanelekileyo)

Bendityelela usapho/abahlobo Bendibukela umabonakude

Bendisenza imisetyenzana yasekhaya Bendingenzi nto

Omnye umsebenzi, nceda ucacise

11. Uhlala phi ngoku?

Endlwini yam Nelungu losapho lwam Kwindlu eqeshiweyo

Kwikhaya labadala

Kwenye indawo, nceda ucacise

12. Uhlala kwisiphi isithili?

13. Uyakwazi ukufikelele kwizinto ezikhwelwayo? Ewe Hayi

14. Ukuba uyakwazi, phawula ngezantsi uhlobo lwento ekhwelwayo odla ngokuyisebenzisa?

Isithuthi sikawonke-wonke (iteksi, ibhasi, itreyini) Isithuthi sabucala

15. Ukuba awukwazi, wenza njani xa kukho indawo ekufuneka uye kuyo?

Uhamba ngeenyawo Usebenzisa isitulo esinamavili Uyanyanzeleka ukuba uhlale ekhaya


ICANDELO B: ULWAZI NGOKUPHATHELENE NE-STROKE

16. Kulithuba elingakanani sikuhlasele i-stroke?

Kwisithuba esingaphantsi kweenyanga ezintathu ezidlulileyo

Kwisithuba esiphakathi kweenyanga ezintathu nezintandathu ezidlulileyo

Ngaphezu kweenyanga ezisixhenxe ezidlulileyo, kodwa kwisithuba esingaphantsi kweenyanga ezili-12

Ngaphezu kweenyanga ezili-12 ezidlulileyo

17. Liliphi icala lomzimba wakho elichaphazelekileyo? (Phawula elichanekileyo)

Lelasekhohlo Lelasekunene Zombini

18. Ingaba walaliswa esibhedlele ngethuba ufumene i-stroke? (Phawula impendulo echanekileyo)

Ewe Hayi

19. Ukuba impendulo yakho ngu-ewe, walaliswa kwisiphi? (Phawula esichanekileyo)

E-Tygerburg E-Groote Schuur E-Somerset

E-Victoria E-G.F.Jooste E-False Bay

E-Eersterivier E-Hottentots Holland E-Stellenbosch

E-Westfleur Kwsibhedlele sabucala

Kwesinye isibhedlele, nceda ucacise

20. Ingaba wawulalisiwe kwiziko lokubuyiselwa kwimeko yesiqhelo? (Phawulaimpendulo echanekileyo)

Ewe Hayi

21. Ukuba uphendule ngo-ewe, wawulaliswe phi?

E-Western Cape Rehabilitation centre E-Panorama

Iziko lonyamekelo laseConradie E-Booth Memorial

Kwelinye iziko, nceda ucacise

22. Wahlala ixesha elingakanani kweli ziko?

Ngaphantsi kweveki enye Iveki enye Phakathi kweveki nezimbini

Phakathi kweeveki ezimbini nezintathu Phakathi kweeveki ezintathu nezine

Ngaphezu kweeveki ezine

23. Ingaba wakhe wafumana enye yezi nkonzo zokubuyiselwa kwimeko yesiqhelozidweliswe ngezantsi apha?

Ewe Hayi

Ukuba uphendule ngo-ewe, nceda uphendule umbuzo 24 no-25.

24. Ziziphi iinkonzo zokubiyeselwa esiqhelweni othe wazifumana? (Phawula echanekileyo ibenye okanye ngaphezulu)

Ukunyanga umzimba ngokwenza imithambo Unyango ngokunika umguli imisebenzi emfaneleyo

Unyango lokubuyisela ukuthetha

Olunye unyango, nceda ucacise

25. Ingaba wazifumana phi ezi nkonzo zokubuyisela imo yempilo esiqhelweni? (Phawula indawo echanekileyo ibe nye okanye ngaphezulu)

Esibhedlele Kwiziko loluntu lezonyango


ICANDELO C: UBUME BEMPILO JIKELELE OKANYE INDLELA YOKUPHILA

26. Uyawutshaya umdiza ngoku?

Ewe Hayi

27. Ukuba uyatshaya, utshaya imidiza emingaphi ngosuku?

1-5 6-10 11-20 21-30 Ngaphezulu kwama-30

28. Ukuba uphendule ngo-hayi kumbuzo 21, ingaba ubutshaya ngethuba ufunyanwa si-stroke?

Ewe Hayi

29. Ukuba ubutshaya ngethuba uhlaselwa si-stroke, kodwa awusatshayi ngoku, wayekiswa yintoni?

30. Uyazisela iziselo ezinxilisayo?

Ewe Hayi

31. Ubusela ngethuba ufunyanwa si-stroke?

Ewe Hayi

32. Ukuba ubukade usela iziselo ezinxilisayo ngethuba uhlaselwa si-stroke, kodwa awusaseli ngoku, wayekiswa yintoni?

33. Ukuba impendulo yakho ngu-ewe kumbuzo 30, udla ngokusela esiphi isiselo esinxilisayo?

Iibhiya Ibhranti okanye iwiski Iwayini

Obunye utywala, nceda ucacise

34. Usela utywala obungakanani ngexesha ngokomyinge?

Itoti enye yebhiya Iitoti ezimbini zebhiya Itoti ezimbini nangaphezulu zebhiya

Ithamo elinye Amathamo amabini Amathamo amathathu

Ngaphezu kwamathamo amathathu Iglasi enye yewayini Iiglasi ezimbini zewayini

Ngaphezulu kweeglasi ezimbini zewayini

Omnye umlinganiselo, nceda ucacise

35. Udla ngokuzisela kangaphi ezi ziselo zinxilisayo ngeveki?

Yonke imihla Kathathu okanye kane Kanye ngeveki

Amaxesha ambalwa enyangeni Manqapha-nqapha okanye awuseli kwaphela

36. Ingaba uyitshintshile indlela yakho okanye uhlobo lokutya okoko wathi waba ne-stroke?

Ewe Hayi

37. Ukuba impendulo ngu-hayi, ziziphi izizathu ezibangela ukuba ungatshintshi indlela nohlobo lokutya okutyayo?

Kuxabisa kakhulu Bendingazi ukuba kufuneka nditshintshe indlela nohlobo lokutya

Andiyazi indlela yokutshintsha kuleyo ndiqhele ukuyisebenzisa yokutya

Esinye isigulo, nceda ucacise

38. Ingaba unaso esinye sezi zigulo zilandelayo? (Phawula impendulo echanekileyo ibe nye okanye ngaphezulu)

Isifo seswekile Uxinzelelo lwengqondo / unxinzelelo lwegazi

Iingxaki zentliziyo Ukutyeba kakhulu okanye ukuba nobunzima obugqithisileyo

Esinye isigulo, nceda ucacise

39. Ingaba akho ameya owasebenzisayo?

Ewe Hayi

40. Ingaba uwasebenzisela ntoni la mayeza?

41. Ingaba uyawasebenzisa njengoko uyalelwe la mayeza? (Phawula impendulo echanekileyo)

Ewe Hayi Maxawambi

42. Ukuba uphendula ngo-hayi okanye maxawambi, nika izizathu?

Ngamanye amaxesha Andizange ndicaciselwe indlela emandisebenzise ngayo amayeza

Andizange ndicaciselwe amaxesha okutya amayeza

Enye impendulo, nceda ucacise

ICANDELO D: ULWAZI NGE-STROKE

43. Ingaba wawukhe wanikezwa naluphi na ulwazi malungane-stroke ngabantu abaqeqeshiweyo bezempilo?

Ewe Hayi

44. Ukuba wawukhe walunikwa, ngubani owakunika ulwazi? (Phawula iimpendulo ezichanekileyo)

Ngugqirha Ugqirha onyanga abaguli ngokubenzisa imithambo

Ngumsebenzi woLuntu kwiCandelo lezeMpilo

Ngugqirha onyanga ngokunika abaguli imisebenzi ebafaneleyo

Ingcali yokunyanga izigulo ezichaphazela ukuthetha Ngunesi

Ngomnye umntu, nceda ucacise

45. Luluphi ulwazi owalunikwayo malunga ne-stroke? (Phawula impendulo echanekileyo ibe nye okanye ngaphezulu)

Yintoni i-stroke? Izinto ezibangela i-stroke

Ulwazi malunga nendlela yokuthintela ukuqhubekela phambi kwe-stroke

Iindlela zokuthintela iingxaki ezifana nezilonda ezibangelwa luxinzelelo, ukuqina kwamalungu omzimba, njalo njalo.

Olunye ulwazi, nceda ucacise

ICANDELO E: INKXASO

46. Yiyiphi inkxaso (ngokwasemphefumlweni nangokwasemzimluyayidinga okoko uthe wahlaselwa si-stroke? (ngokwasemphefumlweni: umz. ingaba udinga inkuthazo xa uziva udakumbile?) (ngokwasemzimbeni : umz. ingaba udinga uncedo olungaphezulu xa uhlamba, unxiba, okanye usenzanantoni usekhaya?)

47. Ucinga ukuba ngubani omakakunike le nkxaso?(Phawula impendulo echanekileyo ibe nye okanye ngaphezulu)

Liqela labantu abane-stroke Lusapho/abahlobo Liqela lenkonzo

Ngabasebenzi bezonyango

Ngomnye umntu, nceda ucacise

48. Ucinga ukuba uyayifumana inkxaso oyidingayo emva kokuba ufunyenwe si-stroke?

Ewe Hayi

49. Ukuba awuyi kwiqela labantu abane-stroke, nika izizathu ezibangela oko?

Izinto zokuhamba zibiza kakhulu

Akukho qela labantu abane-stroke elikufutshane nendawo endihlala kuyo

Bendingazi nto ngamaqela abantu abane-stroke

Andinyanzelekanga ukuba ndiye kwiqela labantu abane-stroke


ICANDELO F: UKUKWAZI UKUHAMBA

50. Ingaba lukho naluphi na unyango olufumanayo lokwenza imisebenzi ekufaneleyo xa kungoku?

Ewe Hayi

51. Ukuba uphendule ngo-Ewe, ingaba unyango lwakho lokwenza imisebenzi ekufaneleyo ulufumana uwedwa okanye niliqela?

Ndindedwa Siliqela

52. Ingaba ukhe uthabathe inxaxheba kuwo nawuphi na umsebenzi osebenzisa umzimba okanye wenze imithambo, efana nokuhamba-hamba, ukuzilolonga, njalo njalo; ukwenza imithambo niliqela labantu abane-stroke rhoqo, isiqingatha seyurengexesha ngalinye?

Ewe Hayi

53. Ukuba uphendule ngo-Ewe, yiyiphi imithambo oyenzayo?

54. Ingaba uyithabatha kangaphi inxaxheba kwimisebenzi yokushukumisa umzimba kangangesiqingatha seyure ubuncinane xesha ngalinye?

Yonke imihla Kathathu ngeveki Kanye ngeveki

Amaxesha ambalwa enyangeni Manqapha-nqapha okanye andithabathi nxaxheba kwaphela

55. Ukuba awuthabathi nxaxheba kulo nuphi na uhlobo lomsebenzi wokushukumisa umzimba, nika izizathu? (Phawula impendulo echanekileyo ibe nye okanye ngaphezulu)

Lixabiso lezinto zokuhamba Andazi ukuba ndiyenze phi na imithambo Ndiswele inkuthazo

Kukho ezinye izinto endizixhaleleyo Ndiswele amandla, andiqinisekanga ukuba ndinganakho


56. Ingaba uyayenza imithambo ekhaya ukuthintela ukuqina kwalungu omzimba ngenxa ye-stroke?

Ewe Hayi

57. Ingaba uyaluhlola ufele kwicala elichaphazeleke si-stroke, ujonge izilonda, rhoqo?

Ewe Hayi

ICANDELO G: IIMFUNO EZICINGELEKAYO ZEMPILO

Nceda usixelele ngenkqubo okanye iinkqubo ongathanda ukufunda ngazo, ukuphucula impilo yakho.

Phawula inkqubo okanye iinkqubo onomdla kuzo:

Ingcasico malunga ne-stroke nezinto ezingunobangela waso

Ulwazi malunga nendlela yokuthintela ukuqhubekela phambi kwe-stroke

Ukufundisa malunga nendlela yokuthintela izilonda ezibangelwa luxinzelelo, kunye nokuqina kwamalungu omzimba

Ukufundisa amalungu osapho okanye abantu abajongene nabantu abagula si-stroke malunga naso

Isikhokhelo malunga nendlela yokumelana nokudakumba nokuswela inkuthazo

Ukufundisa malunga neendlela onokuzikhetha zokuzilolonga kunye neenkqubo zazo

Ukufundisa malunga neengcebiso zokulawula ubunzima bomzimba

Indlela onokuhlala ukwazi ngayo ukwenza imisebenzi yamihla yonke

Ukuthintela okanye ukulawula isifo seswekile okanye i-hypertension

Ukufundisa malunga nendlela yokulawula ukudakumba

Ukufundisa ngendlela yokuyeka ukutshaya

Uxinzelelo lwegazi nonokwenza ngalo

Ukufunda malunga neendlela ezintsha zokuphucula impilo yakho

Ukufundisa malunga noGawulayo neNtsholongwane yakhe neendlela zothintelo

Chaza nayiphi enmye into ongathanda ukuba uyifundiswe ukuphucula impilo yakho.

Siyakubulela ngenxaxheba othe wayithabatha.

Qualitative Interview Guide Tell me what it is like for you to live with a stroke?

How does stroke affect your life?

What are your thoughts on your lifestyle now after having a stroke?

1) What are your views on smoking?

2) What are your views on excessive alcohol use?

3) What kind of food do you normally eat? Do you consider your diet to be a

healthy one, and if yes why?

4) What kind of physical activity (if any) do you do in an average day?

5) Medication usage?

How does your current lifestyle compare to before you had the stroke?

Tell me if anyone has ever talked to you about stroke? If so who and when did

they speak to you?

If you can remember, please tell me exactly what information they told you about

stroke?

How has this information benefited you in your everyday life?

Do you feel it’s important for individuals who have suffered a stroke to be taught

about stroke?

Do you feel you received (are receiving) all the support you needed (need) from

health care professionals at the time of your stroke?

Please tell me whether you receive any support from your family/friends?

Do you think this type of support is important? Why?

Please tell me about any problems you are experiencing since having the stroke

(physical, emotional)

How do you think these problems can be resolved?

What are your views on programmes being implemented, so that you could learn

to improve your lifestyle and learn more about your condition?

health promotion needs of stroke patients accessing ... · health promotion needs of stroke...

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